MADNESS AS MENTAL ILLNESS OR MENTAL ILLNESS AS

MADNESS: MENTAL ILLNESS AS CONSTRUCTED BY YOUNG

PROFESSIONALS

by

MARISSA MORKEL

Submitted in partial fulfillment of the requirements for the degree

MAGISTER ARTIUM

CLINICAL PSYCHOLOGY

in the

FACULTY OF HUMANITIES

UNIVERSITY OF PRETORIA

SUPERVISOR: MISS. A. PAUW

Oct 2007

ii

Dedicated to my husband, Henrico Morkel.

Your wisdom has been an inspiration.

iii

Acknowledgements

I would like to thank the following people who made this work possible:

• Annalie , my supervisor, for her support, patience and insight

• Carol for letting me tap her unparalleled mind in order to write this

dissertation

• My participants who were willing to share their opinions with me.

• My family and friends who have had to take a backseat for a long

time while I was on my journey.

• My colleagues at Weskoppies hospital where I am completing my

internship for their ever available attention and advice when it

seemed I was ready to give up.

Thank you

iv

Abstract

The aim of the study was to explore the constructions and meanings around

madness/mental illness among a group of young professionals in order to

broaden the dialogue around mental illness to include the voices of a certain

section of the community. The current dialogue around mental illness is

dominated by the view that madness/mental illness is the domain of scientifically

trained professionals. The aim of the study was to explore the constructions of

those not part of a mental health profession and those not suffering from mental

illness and how these constructions may influence their behaviour towards those

suffering from mental illness.

The epistemological framework of the study falls into a social constructionist

perspective. This epistemological approach allows for the exploration of

previously taken for granted truths. When adhering to this approach the function

of research is to explore a particular version of reality in an embedded context

and language seen as the structuring aspect of social reality. From this approach

a discourse analysis was done using the transcripts of audiotaped interviews with

the participants. The four participants chosen for the study fell into the 23-26

years age group brackets, had finished tertiary education and have started

working on a professional career. None of the participants have had any formal

contact with mental health services or professionals or those suffering from

mental illness.

In the process of analysing the texts five discourses were identified and

discussed. The first of these discourses was the scientific discourse around

mental illness in which madness is constructed mostly as an illness with genetic,

chemical or emotional causes. The knowledge and expertise of mental health

professionals is seen as important to the general public as they seem to have

little knowledge on the meaning of mental illness themselves. The second

discourse that was identified was mental illness as the domain of professionals

v

and mental institutions. Most of the respondents seemed comfortable with this

idea and used distancing strategies in order to explain their non-involvement in

the care of the mentally ill. Mental illness as individual experience was discussed

next and in this discourse mental illness was seen as an exclusive experience to

which few except the sufferer has access. The fourth discourse discussed was

the mental illness as unknown discourse. In this discourse madness/mental

illness, those suffering from it and the treatment thereof, is a mystery to those

who are not part of these experiences. The final discourse discussed was the

mental illness as bad discourse where those suffering from mental illness were

constructed as dangerous, possibly violent, unpredictable and damaging.

During the analysis of the data it was found that the majority of the respondents

used techniques to distance themselves from involvement of the mentally ill and

ascribed to the discourse that madness/mental illness is the domain of mental

health professionals only.

Key terms

Madness; mental illness; modernism; social constructionism; qualitative research

discourse;

vi

Chapter one

Introduction

1.1 Introduction 2

1.2 Aim of the research 3

1.3 Motivation for the research 4

1.4 Theoretical framework 5

1.5 Process of enquiry 6

1.6 Discourse analysis 6

1.7 Terminology 7

1.8 Conclusion 7

Chapter two

Literature Review:

The differing meaning of mental illness

2.1 Introduction 9

2.2 Historical definitions of madness and its cures 9

2.3 Madness as mental illness 13

2.4 Diagnosing mental illness 16

2.5 The role of the psychiatric patient 19

2.6 Diagnosis as a reflection of power and powerlessness 20

2.7 Cultural factors in the definition of madness 20

2.8 Mental illness and popular culture 22

2.9 Reflections on the literature survey 23

2.10 Conclusion 24

vii

Chapter three

The epistemological framework

3.1 Introduction 26

3.2 Modernism 26

3.2.1 The assumptions of modernism 26

3.3 Social constructionism 28

3.3.1 Realities are socially constructed 29

3.3.2 Realities are constituted through language 30

3.3.3 Realities are organised and maintained through narratives 32

3.3.4 There are no essential truths 33

3.4 The subject in social constructionism 34

3.5 The role of the researcher 34

3.6 Conclusion 35

Chapter four

Methodology

4.1 Introduction 37

4.2 Qualitative research design 37

4.3 Sampling and participants 37

4.4 Data collection 39

4.4.1 Participant interviews 39

4.4.2 Recording and transcribing interviews 40

4.5 Data analysis 41

4.5.1 Discourse 41

4.5.2 Procedure 44

4.6 Ethical considerations 48

4.7 Conclusion 49

viii

Chapter five

Results of the study:

Discourse analysis

5.1 Introduction 51

5.2 Scientific discourse of mental illness 51

5.3 Mental illness as the domain of professionals and mental

institutions 60

5.4 Mental illness as individual experience 66

5.5 Mental illness as unknown 70

5.6 Mental illness as bad 75

5.7 Discussion 81

5.8 Role of the researcher 85

5.9 Conclusion 85

Chapter six

Conclusion

6.1 Introduction 88

6.2 Final reflections 88

6.3 Evaluating discourse analysis 90

6.4 Limitations of the study 92

6.5 Recommendations 93

6.6 Final reflections 94

References 95

1

����������

Introduction

A tree that can fill the spanA tree that can fill the spanA tree that can fill the spanA tree that can fill the span

Of a man’sOf a man’sOf a man’sOf a man’s arms arms arms arms

Grows from a downy tip;Grows from a downy tip;Grows from a downy tip;Grows from a downy tip;

A terrace nine stories highA terrace nine stories highA terrace nine stories highA terrace nine stories high

Rises from hodfuls of earth;Rises from hodfuls of earth;Rises from hodfuls of earth;Rises from hodfuls of earth;

A journey of a thousand miles A journey of a thousand miles A journey of a thousand miles A journey of a thousand miles

Starts from beneath one’s feet.Starts from beneath one’s feet.Starts from beneath one’s feet.Starts from beneath one’s feet.

LAOLAOLAOLAO----TZUTZUTZUTZU

2

1.1 Introduction

Madness has intrigued mankind for centuries. One can argue that the question of

what madness is has accompanied man since the beginning of time.

Over the course of the centuries the meanings around mental illness have shifted

many times according to the societal beliefs and political atmosphere of the day

(Foucault, 1974). The way madness is defined has far-reaching effects on those

who have a mental disorder, and determines how they are treated by

professionals responsible for their care and the society of which they are a part.

Part of the present discourse around mental illness in society today is that it is

the domain of mental health practitioners such as psychologists and psychiatrists

(Mills, 2003). This is the context in which I find myself.

In the course of my tertiary education I have come to be part of the discourse

around madness/mental illness from the perspective of clinical psychology. Some

of the ways in which this discourse shapes my perception begins, for example, in

my use of certain words to describe behaviour outside of the social norm. As I

work in a psychiatric institution I describe my charges as patients suffering from a

mental illness. The rehabilitation of these patients is the responsibility of a

multidisciplinary team of which I am a part, and includes a social worker,

psychiatrist and occupational therapist.

I do not view my patients as dangerous or scary or inherently defective. In

general, I believe that mental illness can ‘happen’ to anyone; most importantly,

this helps me maintain my view of my patients as human beings that, for some

reason or another, have difficulty in living within the society of which they are a

part. My view of what it is to be mentally ill has been shaped by people such as

C.G. Jung, Sigmund Freud, existential phenomenological psychology, systems

theories and postmodern, social constructionist ideas. But this does not mean

that those who are not part of this context do not have constructed meanings

around what it entails to be mentally ill. What are these meanings and what are

3

the processes by which they are constructed? How does this influence these

people’s attitude toward the mentally ill? What are their constructions around the

work that psychologists do? In my various discussions with young adults not in

the field of psychology, I have become aware of stigmatising views, indifferent

attitudes and curiosity toward what it means to be mentally ill. The question then

becomes: what is the view of these young people; and how does it affect their

behaviour towards the mentally ill?

1.2 Aim of the Research

The majority of studies on the meanings of madness have focused on the

patients’ own constructions of their experiences and those of the clinicians who

treat them (Corrigan & Watson, 2002; Gingerich, 1998; Holmes & River, 1998;

Littlewood, 2001). However, little attention has been given to the constructions of

the society to which the patients and clinicians belong.

The aim of the present study was to explore the constructions of madness/mental

illness among young professionals. I aimed to gain a deeper understanding of

their constructions and meanings of madness/mental illness through their own

words. This study formed part of a larger ongoing dialogue around mental illness,

and aimed to illustrate the complexity of experience and meaning related to

mental illness. It aimed to amplify the current view of mental illness as being the

terrain of mental health practitioners only. This was done by broadening the field

of enquiry to include a diversity of voices on this topic in order to explore the

understandings of the community of what it means to be mentally ill. The study

took the form of a discourse analysis of transcribed interviews with young

professionals between the ages of 23 to 26.

4

1.3 Motivation for the Research

The identity of the researcher becomes relevant in discourse analytic research in

a number of ways. Most importantly it influences the choice of the research topic

or research area (Wetherell, Taylor & Yates, 2001). The researcher is likely to

choose a topic which ties in with personal interests, sympathies and political

beliefs. The researcher’s special interests and personal links to the topic are not

in themselves a sufficient basis for research, but they are a probable starting

point for the project.

I am currently completing my internship at a psychiatric hospital in Pretoria. In

many ways it has been a difficult experience for me. I have become aware of the

profound suffering of the patients with whom I work. Many struggle with

accepting a psychiatric diagnosis and with finding meaning in their lives. For me

it was interesting to see how large a part their being diagnosed with a mental

illness played in their difficulties. The patients often experienced the diagnosis as

a derogatory label, and felt that it describes them as being inherently defective

even though they experience themselves mostly as being the same as everyone

else, or as having special attributes. Many of my patients ascribe different

meanings to their condition: for example, they might see themselves as being the

chosen prophet of God, being more sensitive than others, or as having a greater

capacity to feel and understand life and its complexities. I began to explore what

my personal views were on being mentally ill and realised that I have many

ambivalent feelings about describing people as mentally ill. In most of the lives of

my patients there has been some very real neglect and difficult circumstances,

and I feel it is no wonder that they experience psychological distress. Defining

these people as ill feels to me to be a very narrow description of their

experiences. I also began to wonder how people outside the mental illness

discourse see madness. How do they understand it for themselves if I, who am

part of the discourse, already have conflicting ideas around it? This sparked my

interest in researching the meanings surrounding mental illness.

5

A second important factor in considering this research topic was the reaction to

patients of society outside the hospital. In conversations with various individuals I

have become aware that the meanings they attach to mental illness differ

considerably from my own. Often, these meanings do not engender empathy and

compassion; rather it may provoke fear and avoidance.

In her budget speech on 17 June 2004, the deputy Minister of Health, Nozizwe

Madlala-Routledge, spoke about the movement introduced by the passing of the

Mental Health Care Act to integrate the care of mentally ill patients into the

community setting (Madlala-Routledge, 2004). Addressing parliament, she stated

that:

There will be an increasing demand on our clinics and hospitals to

provide treatment and on NGO's to expand services. There has been

progress in developing community capacity to care for mentally ill

people… (Madlala-Routledge, 2004, para. 5).

If the integration of the mentally ill into the community is an objective for the

South African Department of Health, then surely the community’s view on what it

means to be mentally ill, and how this view influences their behaviour towards

the mentally ill, is of great importance.

1.4 Theoretical Framework

The guiding epistemology of this study falls within the postmodern, social

constructionist framework. The assumptions adhered to in this type of study are

very different from the assumptions of modernist research (Wetherell, Taylor &

Yates, 2001), in that the goal is not to formulate objective descriptions of static

and measurable reality; instead, it is a subjective, qualitative description of

constantly changing realities and truths (Hanson, 1995). Thus the focal point is

the myriad of possible meanings of madness/mental illness.

6

1.5 Process of Enquiry

A qualitative research design was selected because qualitative research tends to

be concerned with meaning (Willig, 2001), and thus lends itself particularly well to

the study of the meanings on mental illness.

Because in-depth, semi-structured, open-ended interviews offer greater freedom

and fewer restrictions for the participants, this method was selected as the

means for gathering data (Meese, 2005). Although the questions in the

interviews are similar, the interviews were driven by the responses and

information that the participants presented.

Using Parker’s (1992) seven stage guidelines as a basis, a discourse analysis

was conducted to give a textured view of the different meanings on mental

illness. According to Burr (1995, p.48),

a discourse refers to a set of meanings, metaphors, representations,

images, stories, statements and so on that in some way together produce

a particular version of events. It refers to a particular picture of an event

(or person or class of persons), a particular way of presenting it or them in

a certain light.

In order to understand the current dialogue on mental illness, it is important to

look at some of the meanings around it.

1.6 Discourse Analysis

The findings of the discourse analysis were discussed according to five central

discourses. These discourses were: the scientific discourse of mental illness,

mental illness as the domain of professionals and mental institutions, mental

illness as individual experience, mental illness as unknown and mental illness as

bad. The findings were integrated with the relevant literature as discussed in the

literature review. Throughout the process I reflected on my part in shaping certain

7

conversations, my influence in the analysis of data and my reflections on the

literature on the meanings of madness/mental illness.

1.7 Terminology

A variety of terms were used to denote mental health problems in this study,

including mental illness, mental disorder and madness. This reflects the diversity

of interpretation of this phenomenon. No single term is privileged over another

because all are equally meaningful (or meaningless), depending on the

experience and perceptions of the individuals (Casey & Long, 2003). However, in

discussing the results, the power of the term ‘mental illness’ to categorise and

refer to a wide range of abnormal behaviours made it convenient to lean heavily

on the term. As such, this term may occur more frequently throughout the text. It

may also reflect my position within the “madness as mental illness” discourse

and the way that my understandings of madness are shaped by it.

1.8 Conclusion

In summary, this study aimed to explore the diversity of the meanings

surrounding mental illness in young professionals between the ages of 23 and

26. The social constructionist epistemology acknowledges that social realities are

constructed through the language we use, and therefore a discourse analysis on

the family of words used by the participants to describe mental illness was

considered appropriate to highlight the lived reality of the society of which those

with mental health problems are a part.

8

������������

Literature Review:

The differing meanings of mental

health problems

What’s madness but nobility of soul

At odds with circumstances

Roethke

9

2.1 Introduction

Questions of how to define and treat what is now called mental illness have

troubled civilizations throughout history. Public fascination with madness has

shaped a broad spectrum of historical and contemporary popular culture, from

Shakespeare’s plays to television talk shows and supermarket tabloids (Connor-

Greene, 2006). One can argue that these questions are as old as humanity

itself, but the meanings surrounding what it entails to be ‘mad’ have changed

over time. What were those meanings then, and what are they now? What do

they mean for those then that do not behave according to the social norm?

A recent pamphlet published by the National Alliance for the Mentally Ill (NAMI)

(cited in Fee, 2000, p.1) asserts on its first page that “mental illnesses are

disorders of the brain that disrupt a person’s thinking, feeling, moods, and ability

to relate to others. Just as diabetes is a disorder of the pancreas, mental

illnesses are brain disorders… [They] are not the result of personal weakness,

lack of character, or poor upbringing.” This pamphlet seems to assume that the

only way to view mental illness is that it is a purely medical condition situated in

the individual (Fee, 2000). This represents a radical view of the madness as

mental illness discourse. According to Fee (2000), “our modern understanding of

mental disorder, an Enlightenment product, was created through the

understanding that disorders were ‘alien’ – external and irrational maladies to be

fathomed and hopefully rectified by the scientific expert, imbued with mysterious

powers of moral adjudication” (p. 3). But madness was not always seen as a

mental illness/disorder. There have been many times throughout history that it

was understood and treated in different ways.

2.2 Historical Definitions of Madness and its Cures

In his work Madness and Civilization (1974), Foucault asserted that madness

should not be considered a stable condition, but that it should rather be seen as

10

the result of social contradictions in which humans are historically alienated.

According to Mills (2003), Foucault is one of the leading theorists that trace the

way that madness has been constructed and judged throughout history. In this

seminal work Foucault shows that in the Classical period, rather than being

classified as a mental illness as we do now, madness was seen as a

manifestation of animality (Foucault, 1974; Mills, 2003). As he states

Madness borrowed its face from the mask of the beast. Those chained to

the walls were no longer men whose minds had wandered, but beasts

preyed upon by a natural frenzy: as if madness, at its extreme point, freed

from that moral unreason in which its most attenuated forms are enclosed,

managed to rejoin, by a paroxysm of strength, the immediate violence of

animality. (Foucault, 1974, p. 74)

In the age of Enlightenment when logic or reason was seen as man’s crowning

achievement and the characteristic that differentiates man from beast, madness

was seen as the loss of reason, or as Foucault describes it, unreason (Foucault,

1974). Madness eradicated that which was human in man, and those afflicted by

madness therefore became bestial. This had a profound impact on how the mad

were treated at that time. If madness is seen as a manifestation of animality, then

the only way to curb its passion is discipline and brutal methods (Foucault, 1974;

Mills, 2003). As such, confinement of the insane became a practice to protect

humanity from what is bestial. In describing the practices of that time Foucault

states that: “This model of animality prevailed in asylums and gave them their

cagelike aspect, their look of a menagerie” (1974, p. 72). People were chained to

the walls or kept in cells with bars and straw to cover the floor (Foucault, 1974).

Foucault also explores the strange treatments of madness which developed in

the eighteenth century, when the meanings of madness evolved yet again and

were seen as caused by an imbalance in the humours. Patients were given blood

transfusions, were shocked by sudden immersions in cold water, and were

forced to ingest bitters (Foucault, 1974; Mills, 2003).

11

Many of the treatments that were thought to be innovative and promising seem

almost cruel by our modern day standards. Treatments that today seem

unfounded, ineffective or even dangerous developed from the dominant definition

of madness/mental illness within a particular historical period (Connor-Greene,

2006). In 1916, a time when bacteriological theories of disease gained scientific

and popular support, a prominent physician, Dr. Henry Cotton, hypothesised a

focal infection theory of schizophrenia (Connor-Greene, 2006). In an attempt to

remove the site of the infection he resorted to extracting the teeth of patients. He

was so convinced of the validity of his theory that when this did not cure these

individuals, he removed various internal organs, including the stomach, liver and

uterus.

In Madness and Civilisation (1974), Foucault examines the way that institutional

change, such as the availability of houses of confinement, contributed to the

development of a distinction between madness and sanity, and does not assume

that the distinction between madness and sanity is self-evident. Foucault shows

how the institutionalisation of the insane developed from the twelfth century

practice of confining people with leprosy (Foucault, 1974). Leper houses were

built in order to protect the population from the spread of this highly infectious

disease. Largely due to the removal of infectious people from general society

through confinement and the end of the Crusade that brought people into contact

with infectious agents from the East, leprosy had largely disappeared from

Europe by the end of the sixteenth century (Foucault, 1974; Mills, 2003). By the

end of the seventeenth century houses that were built for the confinement of

lepers were largely taken over to be used as asylums for the ‘socially useless’.

For example, those who could not and would not work were placed in these

houses along with the poor and those who had disgraced their families (Foucault,

1974; Mills, 2003). Foucault (1974, p. 62) states:

But in the history of unreason, it marked a decisive event: the moment

when madness was perceived on the social horizon of poverty, of

12

incapacity for work, of inability to integrate with the group; the moment

when madness began to rank among the problems of the city.

The confinement of this very diverse group of people was not enacted on

grounds of medical incapacity or with the aim of curing the confined. In the

nineteenth century these houses began to be used solely for confining those who

were considered insane (Foucault, 1974; Mills, 2003).

With the shift towards defining madness as a mental illness, behaviour such as

hearing voices, speaking in tongues or hallucinations that would in another

period in history have been seen as possessions by spirits or God became

something that needed to be treated by confinement and the administration of

drugs (Mills, 2003). Foucault (1974) refers to this in his statement that

In the Middle Ages and until the Renaissance, man’s dispute with

madness was a dramatic debate in which he confronted the secret powers

of the world; the experience of madness was clouded by images of the

Fall and the Will of God, of the Beast and the Metamorphosis, and of all

the marvellous secrets of knowledge. In our era, the experience of

madness remains silent in the composure which, knowing too much about

madness, forgets it. (p. xiv)

In medieval Europe madness was conceptualised around the central concepts of

demonic possession and witchcraft (Castillo, 1998). The Christian church defined

society’s view of nature. Therefore, life in the world was defined as a constant

struggle between the forces of God and Satan. The mad were seen as either

possessed or the victims of witchcraft, and therefore the ‘cure’ of the ‘mad’ was

the responsibility of the church through religious rituals and purification (Castillo,

1998). The preferred method of treatment for demonic possession was exorcism

(Nevid, Rathus & Greene, 2000). Exorcism was used to try and persuade evil

spirits that the bodies of their victims were basically uninhabitable. Methods

included prayer, waving a cross at the victim, beating, flogging and even starving

the victim. If undesirable behaviour persisted then even more powerful remedies

13

like the rack (a torture device) was employed (Nevid et al., 2000). During the late

fifteenth through the late seventeenth century the dominant explanation of

abnormal behaviour was witchcraft in which the person entered into a pact with

the devil and hence could perform impressive feats such as flying and having

sexual intercourse with the devil (Nevid et al., 2000). It was believed that witches

committed terrible act such as poisoning crops and eating babies; and in 1484,

Pope Innocent VIII decreed that all witches be executed. Certain tests were

devised to find out if someone was involved in witchcraft. One was the water-float

test, which was based on the principle that pure metals settle to the bottom of

smelting and impurities bob on the surface. Suspects of witchcraft were thrown

into a river bound hand to foot. If they sank and drowned they were cleared of all

suspicions. If they managed to keep their heads above water they were executed

for witchcraft mostly through burning (Nevid et al., 2000).

2.3 Madness as Mental Illness

During the first half of the eighteenth century, a strong psychosocial approach to

madness called moral therapy (Taubes, 1998) became influential. Its basic

assumptions included treating institutionalised patients as normally as possible in

a setting that encouraged and reinforced normal social interaction. Moral therapy

as a system originated with Philippe Pinel (1745-1826) (Barlow & Durand, 2002).

Asylums had appeared in the sixteenth century, but they were more like prisons

than hospitals. It was the rise of moral therapy in Europe and the United States

that made institutions more liveable and even therapeutic (Barlow & Durand,

2002).

Although it is difficult to pinpoint the exact development of the biological

explanation of madness, the biological tradition developed rapidly in the

nineteenth century after the discovery of the nature and cause of syphilis (Barlow

& Durand, 2002). Behavioural and cognitive symptoms of advanced syphilis

include delusions of persecution, delusions of grandeur and other bizarre

14

behaviours. Although these behaviours appeared to be the same as psychosis, a

subgroup of these patients seemed to deteriorate and become paralysed and die

within five years of onset. This contrasted with most psychotic patients who

remained fairly stable. Louis Pasteur’s 1870 germ theory of disease enabled the

identification of the specific bacterial micro-organism that caused syphilis (Barlow

& Durand, 2002). Ultimately it was found that penicillin cures syphilis or general

paresis as it was called. Many mental health professionals then assumed that

similar causes might be discovered for all abnormal behaviours and came to

believe that physical causes were always the reason for abnormal behaviour.

This led to the development of many new treatments. By the end of the 1800s a

scientific approach to madness and its classification had begun with the search

for biological causes (Barlow & Durand, 2002). According to Tone (2005), after

World War II, psychiatrists applied the rhetoric and findings of neuroscience to

explain mental illness. The suggestion that mental illness had neurobiological

origins destigmatised mental illness to a large extent, for it defined it in the same

way as other diseases such as cancer; and as such, mental illness was

deserving of dignity and medical attention. However, not everyone has such a

positive view of these developments.

In an interview with Miller (1983), Szasz states that the distinction of madness as

a mental illness developed after the Enlightenment period, in about the 1850s,

with the development of medical microscopy. It was then that the idea of disease

as tissue damage or bodily illness developed. It was during this same period,

when the concept of disease changed from humoral to cellular, that the idea of

insanity changed from madness to mental illness (Miller, 1983). Szazs argues

that this change is linked to the operational approach to mental illness:

psychiatry. According to him, the patient is a creation of the psychiatrist, much as

the heretic is a creation of the theologian; and the two concepts grew together.

Szazs (in Miller, 1983) argues that madness is misrepresented as a disease and

that the myth of mental illness has given the medical profession dangerously

15

unlimited license to imprison and manipulate mad people in the name of

philanthropy.

The classification of madness as a disease represents, according to Szazs, a

tragic error in philosophical judgement. Echoing Foucault, he states that in the

eighteenth century the dominant part of society was confronted with a class of

people who did not fit in. Those who did not fit into society were alienated. But

society at that time could not morally lock up people who did not fit in and were

not criminals of sort who deserved to be locked up. The only way to remove them

from society was by classifying them as ‘sick’ and then hospitalising them. He

believes that the hospitalisation of the mentally ill is a form of social control with

two effects. One is to remove the unpleasant elements from society, and the

other is to protect the people themselves, who are often so alienated that they

are homeless and unwanted by relatives. According to Foucault (1995), there is

not a single culture in the world where everything is permitted. He argues that

humanity does not start from freedom but from limitation and the line not to be

crossed.

Szasz believes that all psychiatric approaches are fundamentally flawed because

they look for solutions along medical-technical lines. But what are the solutions

for? According to Szazs (quoted in Miller, 1983, p.30): “For Life! But life is not a

problem to be solved. Life is something to be lived, as intelligently, as

competently, as well as we can, day in and day out. Life is something we must

endure. There is no solution for it.”

Psychiatrists such as R.D. Laing (1965) have argued that mental illness

represents an eloquent protest on the part of the patient, and that psychosis, for

instance, enables the individual to escape from the intolerable psychological

pressures exerted by tyrannical families and uncaring societies. Laing insists that

the physical treatment of these illnesses is an elaborate way of evading the

political issues involved, and that therapeutic regimes in modern hospitals

16

express the ideals of a society eager to see its members behave in a

conveniently decorous and economically productive manner. Laing (1965) also

states that the clinical psychiatric approach to mental illness is too narrow as it

only looks at certain aspects of the experience of mental illness. Laing (1965) is

of the opinion that the vocabulary used by clinical psychiatry is too reductionist in

nature:

Technical vocabulary either refers to man in isolation from the other and

the world, that is, as an entity not essentially ‘in relation to’ the other and in

a world, or they refer to falsely substantialized aspects of this isolated

entity. (Laing, 1965, p. 17)

This critique of the language used by psychiatry to categorise persons with a

mental illness is echoed in more recent writings from the social constructionist

worldview.

2.4 Diagnosing Mental Illness

In an article by Mirowski and Ross (1989), the authors focus on how the linguistic

legacy of the eighteenth century development of biology and epidemiology has

influenced the development of psychiatric definitions and explanations of mental

illness. According to the authors,

Superimposing a diagnosis on a person’s symptoms and situation does

not add information; rather, it removes information. Worse still, it entices

us to think, talk, and act as if a hidden entity has been revealed. The

mythical entity insinuates itself into the role of a named actor, and the

symptoms and situation dissolve into mere signs of its presence.

(Mirowski & Ross, 1989, p. 12)

These ‘hidden entities’ that the authors refer to are the presupposed biological

basis for mental illness. Although studies have not conclusively indicated

biological causes for mental illness, the model of the language used to

conceptualise it presupposes such a basis, and therefore justifies the use of

biochemical treatment (Mirowski & Ross, 1989).

17

These authors also reflect on the socially constructed need for a diagnostic

system. Government agencies and insurance companies want to know exactly

where the boundaries for reimbursement are drawn. Psychiatrists and other

physicians want to sell their services. The pharmaceutical industry wants to sell

its drugs. Government and the insurance industry want to know what it is all

going to cost. Insurance companies will only pay for specific cases of mental

illness. In this way society has constructed the need for a classification system

(Mirowski & Ross, 1989).

In terms of diagnosis and the biological approach to mental illness, an

observation by Derrol Palmer (2000) represents an intriguing paradox in medical

psychiatry. He states that symptoms or ‘disorderly conduct’ are identified on a

social rather than a biological basis. The importance of biological knowledge in

diagnosis is undermined by the fact that symptoms could be identified long

before the biological origins of the condition were known. Rosen (1968) reports

cases of hallucinations and delusions in ancient Greece that were treated as

such. Palmer asserts that how a symptom is identified and what causes it are

separate issues. The judgment of ‘pathology’ involves ascribing meaning to a

person’s actions and how they make sense in a particular social setting. So some

actions acquire symptomatic significance not because they contravene the laws

of biological functioning but because they infringe on the social order. Palmer

further states that the social constructionist worldview reconceptualises delusions

as the product of a power relationship where the views of the less powerful

patient are pathologised (Palmer, 2000).

Not everyone has this negative view of the use of psychiatric language in order to

define madness/mental illness. Gough (1971) states that the goal of diagnosis is

not to label or stigmatise those with a mental illness, although it may be an

unfortunate byproduct or effect of diagnosis or the abuse thereof. He feels that

the goal of diagnosis is rather to identify the problem a patient has presented in

such a way that the appropriate treatment for the restoration of the patient can be

18

carried out. According to Gough, there are three levels of diagnosis. The first

level is aimed at identifying and clustering certain symptoms together to be able

to identify a disorder. Treatment that results from a diagnosis at level one is

aimed at relieving and not curing symptoms. Gough believes that most

diagnoses aim toward at least a level two diagnosis, which is concerned with the

underlying pathology that causes symptoms. Thus, the treatment at this level is

curative and brings about more than only symptomatic relief. However, the ideal

is for clinicians to strive towards a level three diagnosis. This is the most basic

level of diagnosis, and at this level, aetiological factors are identified. Once the

aetiological factors are identified, there is the possibility of designing

interventions aimed at prevention. At this level lies the value of careful

conceptualisation and understanding of mental disorders.

The psychiatric diagnosis is also often adopted by people who experience mental

distress in order to structure and explain their experiences (Casey & Long, 2003).

Some people find that having a name for their problems provides them with a

sense of order and a way to reconstruct their lives. Concerning her diagnosis of

manic depression, McIntosh (cited in Casey & Long, 2003, p. 94) reflects:

On a positive note, at least when I did learn of my diagnosis I was able to

begin coming to terms with my illness and dealing with it on a constructive

basis…I discovered a common identity and a camaraderie with fellow

MD’s, which enhanced my life tremendously.

Peters et al. (cited in Casey & Long, 2003, p. 94) talk about the discomfort of not

having a name for disconcerting experiences: “Not having a label, I think that’s

the real problem so I can put it in a box and go ‘yeah’ it’s that. I’ve got that now I

can get on with me life. I can’t deal with the unknown.” A diagnosis along medical

technical lines also relieves some people of a sense of guilt and self-blame

(Casey & Long, 2003).

19

2.5 The Role of the Psychiatric Patient

Mills (2003) reflects that the understanding of madness as a mental illness has

resulted in the alleviation of suffering for many people, but according to her, this

has also resulted in a greater stigmatisation of mental illness, and has placed

responsibility for the ‘cure’ of madness in the hands of professional psychiatrists

and psychologists (Mills, 2003).

Research shows that persons with severe mental illness must cope not only with

the symptoms of their disease but also with social and self-stigma. Societal

attitudes toward severe mental illness lead to lost opportunities for education,

employment and housing (Holmes & River, 1998). Self-stigma occurs when

individuals assimilate social stereotypes about themselves as persons with

severe mental illness. In an article by Corrigan (2007), he discusses the ways in

which diagnosis can increase the stigma of mental illness. He shows that many

people who are in need of mental health services avoid using them so as not to

be labelled a “mental patient” or suffer the prejudice and discrimination the label

brings. People with mental illness who live in a society that widely accepts

stigmatising ideas may internalise these ideas and believe that they are less

valued than others because of their mental illness. According to Corrigan (2007),

the process of diagnosis both accentuates the “groupness” of those with a mental

illness and simultaneously emphasises their “differentness” from the general

public.

The hospitalisation of persons with mental illness also has another and important

effect. A study by Corrigan, Green, Lundin, Kubiak and Penn (2001) has shown

that unfamiliarity with mental illness heightens stigmatising attitudes. The

segregation of the mentally ill into mental institutions to which the general public

have no access heightens stigma towards those with a mental illness and

classifies them as dangerous and incompetent.

20

2.6 Diagnosis as a Reflection of Power and Powerlessness

In a powerful example of how the diagnosis of mental illness reflects the political

and societal influences of the time, Connor-Greene (2006) describes how a New

Orleans physician published seven articles in 1851 in which he described two

mental disorders ‘observed’ in African slaves. “Draepotomania” was a disease

that prompted slaves to run away and “dysaesthesia aethiopica” referred to

lethargy and a partial loss of sensation in the skin, supposedly found in slaves

whose owners allowed them too much freedom. These people were classified as

‘sick’ if they did not behave according to the dominant political view of this age,

which justified enslavement. In this way madness and the meanings surrounding

it become inextricably bound to power and politics.

Women have also historically experienced this phenomenon. In the same article,

Connor-Greene (2006) cites how women in the 1800s who were too outspoken

or independent for the norms of their time were diagnosed as mentally ill.

2.7 Cultural Factors in the Definition of Madness

Although madness as mental illness seems to be the dominant Western view of

madness, it is by no means the only view of what it means to be ‘mad’. The

symptoms of madness or mental illness occur in all cultures of the world but have

different meanings in different cultural contexts. Evidence suggests that

meanings of mental illness have a significant impact on the subjective experience

thereof, the idioms used in the expression thereof, the indigenous treatment, and

the outcome (Castillo, 1998). Thus the societal understandings of madness are

central to the problem of mental illness. In the African view of abnormal

behaviour the biological, sociocultural and the transpersonal aspects being are

integrated, and the interpersonal is united with the intrapersonal domain

(Beuster, 1997). Traditional Africans define abnormal behaviour in terms of

fractured and disharmonious relationships. Behaviours that threaten the social

21

well-being and stability of the community are seen as pathological, and include

animosity, aggressiveness, arrogance, selfishness and envy (Beuster, 1997).

Abnormal behaviour may also be the result of disharmony with the ancestors.

The African model of madness/mental illness is more holistic that the Western

viewpoint. For example, this approach makes a no distinction between mental

and physical illness. Traditional Africans believe that physical and psychosocial

systems are interconnected and change in the one inevitable affects the others.

In traditional African cosmology the causes of abnormal behaviour are mostly

assigned to external and personalised forces (Beuster, 1997). Beuster (1997)

adds that, in South Africa, many people believe that malevolent persons such as

witches and sorcerers can cause mental disorder and illness, or that God may

afflict individuals with mental illness. The African approach to diagnosis and

treatment is more intuitive, experiential and symbolic. The healer, who is called

the sangoma, is expected to make a diagnosis based on divination and treatment

is often more nonverbal and occurs through symbolic acts like chanting and

dancing (Beuster, 1997).

Blazer (2007) cites a study conducted in Ghana with women who were

depressed during their menopause. The study concluded that because the

women could no longer bear children, they developed depression. They visited a

shrine in order to gain relief. Their depression arose from the fear of sorcery and

evil spirits that made them barren. They felt useless as they could no longer bear

children and this made them witches. These women were not considered

mentally ill by their community, for if they believed that they had caused harm to

others, they were taken at their word. If the woman was restless, agitated and

unable to sleep, she had been overtaken by a spirit. It is clear from this study and

the example discussed above that madness has many different explanations in

different cultures, and that these are important in understanding the meaning of

the individual’s experience.

22

2.8 Mental Illness and Popular Culture

Popular culture reflects and shapes interpretations of both the causes and the

consequences of mental illness (Connor-Greene, 2006). Contemporary television

and movies often present skewed images of the mentally ill. At one extreme the

media sensationalise and distort mental illness by linking it with violence in the

familiar psychotic killer (Connor-Greene, 2006); and at the other extreme

television talk shows often oversimplify and trivialise complex mental health

problems and treatment (Connor-Greene, 2006). Both ends of this dichotomy

ignore and misrepresent the experiences of the vast majority of people with

mental illness.

In the last 12 years media studies have started to address the problem of

stigmatisation of mental illness in the media. One of the most important of such

studies is Otto Wahl’s 1995 book Media madness (cited in Harper, 2005). He

enlists a vast range of popular texts and genres to support his argument on the

treatment of madness in the media. He argues, for example, that newspaper

stories that link mental illness and violence contain the same stock characters as

those found in popular fiction such as American Psycho (1991) and Red Dragon

(1993), namely, “insane killers who prey on multiple innocent victims” (Wahl,

1995, cited in Harper, 2005, p.463). He argues that the media over-represents a

link between mental illness and violence.

In reaction to Wahl’s book, Stephen Harper (2005) examines the mental illness,

violence and media discourse. He agrees with Wahl in stating that the media in

all their forms often present the mentally ill as violent. In film and television

drama, for example, the mentally ill are often presented as unpredictable killers,

which create misleading impressions that people with mental illness are to be

feared. This is the reason that one of the main contentions of the anti-stigma

discourse is that media images of mental illness imply an association or link

between mental illness and violence that does not exist. However, he states that

23

a fundamental problem with such critiques is that a correlation between mental

illness and violence has been demonstrated in several studies. According to

Harper, the concern here is that while anti-stigma critics rightly point out the ways

in which the media contribute to public misconceptions about mental illness, their

own arguments can have a similarly distorting effect (Harper, 2005).

2.9 Reflections on the Literature Survey

Most of the literature discussed in this survey forms either an argument for or

against the construction of madness as a mental illness. Using such a

dichotomous method of reasoning loses some of the complexity and

ambivalence of the issue. Working as an intern psychologist, it seems to me that

there is no clear-cut way in which to classify the ‘madness as mental illness’

construction - most of all not either good or bad. Many of the treatments that

flowed from different ways of understanding madness were cruel and dangerous

for those who did not act according to the social norm. Constructing madness as

an illness elicits less cruelty on the part of treating professionals than did many of

its historical precedents.

This being said, this construction may also constrict people’s experience and

meaning-making process of mental illness, and may disqualify any different view

of their experiences. Constructing madness as a mental illness narrows the

experience of these individuals and could leave them voiceless in the hands of

specially trained experts who define and treat their experience.

For me, the value or non-value of the construction of madness as mental illness

lie somewhere between these two extremes. The meanings we attach to our

lives and experiences differ from individual to individual, and as such we

understand and need to understand things in different ways. For some, the

construction of madness as mental illness may be beneficial in structuring and

understanding their experiences; while for others it may be too narrow and

24

dominating. I find myself ambivalent in the way I judge the construct, oscillating

between the two extremes of good and bad, yet able to see the value in both

arguments.

This ambiguous position informed my approach to the study and the analysis of

the data, and is evident in my description of the discourses on madness/mental

illness. At times, the construct of madness as mental illness is seen as allowing

less prejudice against those with it, and in certain discourses this construction

seems to invite distance from those who have a mental illness.

2.10 Conclusion

It is clear that the meanings attached to mental illness are varied and have

changed many times throughout history. They are shaped by the dominant

political, scientific and cultural discourses of the day. They also reflect social

inequalities and imbalances of power. Throughout history the meanings attached

to madness have had far-reaching effects on the experience of mental illness

and the reaction of society towards those defined as having a mental illness. This

leads to the question asked in this study: “What are those meanings in the South

African community today, and how do they influence the way the public behaves

towards the mentally ill?”

25

�������� �����

Epistemological Framework

I know I’m noI know I’m noI know I’m noI know I’m not seeing things as they are,t seeing things as they are,t seeing things as they are,t seeing things as they are, I’m seeing things as I am.I’m seeing things as I am.I’m seeing things as I am.I’m seeing things as I am. Laurel LeeLaurel LeeLaurel LeeLaurel Lee

26

3.1 Introduction

In philosophy, epistemology by definition pertains to “how we know what we

know, or how we can make valid knowledge claims based on a particular

theoretical framework” (Becvar & Becvar, 2000, p. xiv). My epistemological

approach towards this research is influenced by my personal belief system and

the lens through which I see the world, thus bias is inevitable and I recognise that

the way I see things and analyse information is one way (and not the only way) to

think about these discourses. My choice of approach is also influenced by the

nature of the research question. In order to explore the different discourses

around madness/mental illness I have adopted a social constructionist

epistemology. This allowed me to explore the meanings of these different

language systems in more detail.

In this chapter the different assumptions of the social constructionist worldview

are described. It is important, however, to take a brief detour into the modernist

approach to research to fully understand the assumption of the social

constructionist worldview.

3.2 Modernism

At its core, modernity attempts to describe the world and to view knowledge in

rational, empirical and objective terms. It is characterised by a positivistic search

for a truth and an accumulation of knowledge (Kvale, 1992a) that could be

uncovered in variously prescribed ways, especially through the scientific method.

3.2.1 The Assumptions of Modernism

Modernism is associated with the physical sciences and embraces positivism

and postpositivism. The epistemological approaches to research that fall in this

27

category are in themselves broad and varied but they share certain assumptions

(Wetherell, Taylor & Yates, 2001).

One such an assumption is that through the use of appropriate methods, which

have become well established, the researcher can obtain knowledge of the world

and its workings, particularly of the causal relationships which operate within it.

From this standpoint, relationships can be seen as dichotomous interactions

between distinct entities, which can be broken down into their component parts,

and must necessarily be studied in isolation in order to be understood (Becvar &

Becvar, 1996). Identifying such relationships enables a researcher to apply the

research to real-world problems by making accurate predictions and possibly

interventions. The knowledge obtained through the research is generalisable to

other contexts because it is universal (Wetherell et al., 2001). Students of

modernist thought believe that laws exist which govern human behaviour, and

that these laws are absolute and external to us (Becvar & Becvar, 1996).

Another claim made in this tradition is that research produces knowledge that is

value-free and objective, unaffected by any personal bias or worldview of the

researcher (Wetherell et al., 2001). The modernist understanding of the mind and

body as being essentially separate is inherent in the assumption that the mind

and reality can exist independently from each other; thus individual A

(subject/mind) can objectively view B (object/reality) (Becvar & Becvar, 1996).

This premise leads to the belief that objective measurement and value-free

science are possible, and contributes to the widespread mistrust of the subjective

dimension (Meese, 2005). Good research is considered to produce neutral

information and to contribute to a cumulative process that aspires to universal

truths. The whole or final truth about the world may not be attainable; however,

successive researchers attempt to approach this goal by testing hypotheses and

taking a fallibilistic approach in which previous findings are treated as provisional

and open to further testing (Wetherell et al., 2001).

28

The view of madness as a mental illness has at its base the epistemological

claims of the modernist tradition. The medical view of madness as

operationalised by psychiatry assumes that mental illness is a static objective

truth for which the correct definition, cause and cure can be obtained through

careful and systematic inquiry. Mental illness is a problem that exists “out there”

in a “real knowable reality” (Becvar & Becvar, 2000, p. 89).

So here is one set of related claims: that research produces knowledge which is

universal, in that it holds across different situations and different times, and is

value free. In ordinary terms, this is knowledge with the status of truth: it is

enduring and it is separate from the opinions and values of the researcher.

A contrasting tradition is more strongly associated with the social than the

physical sciences, and underlying it are quite different epistemological claims. It

is to a discussion of these claims that we turn next.

3.3 Social Constructionism

Social constructionism draws attention to the fact that human experience,

including perception, is mediated historically, culturally and linguistically. That is,

what we perceive and experience is never a direct reflection of environmental

conditions but must be understood as a specific reading of these conditions

(Willig, 2001). The use of a social constructionist metaphor opens the possibility

for one to consider the ways in which every human being’s social, interpersonal

reality is constructed through interaction with other human beings and social

institutions; and focuses on the influence of social realities on the meaning of

people's lives (Burr, 1995; Freedman & Combs, 1996; Gergen, 1999).The

metaphors by which we structure our lives have a profound impact on what we

perceive and what we do.

29

Adopting a postmodern, social constructionist worldview offers useful ideas about

how the ‘truth’ around mental illness/madness is negotiated in families and larger

cultural groups; and rather than being a stable objective entity to be ‘found’ or

‘explained’ by scientific enquiry, it is a fluid evolving concept embedded in

culture. Some of the epistemological claims that relate to this worldview

(Freedman & Combs, 1996) and that are important to the present study are

discussed below.

3.3.1 Realities are Socially Constructed

A central tenet of social constructionism is that beliefs, laws, social customs (and

therefore meanings around madness/mental illness) – all the things that make up

the psychological fabric of ‘reality’ – are the products of social interaction over

time (Freedman & Combs, 1996). Our shared versions of reality are shaped by

the goings-on between people in the course of their everyday lives. Burr (1995)

states that the implication of this is that realities and therefore narratives are

historically and culturally relative.

Kenneth Gergen (1999, p.50) reflects on the tradition of modernism and the

future of psychology:

If we are to build together toward a more viable future then we must be

prepared to doubt everything we have accepted as real, true, right,

necessary or essential. This kind of critical reflection is not necessarily a

prelude to rejecting our major traditions. It is simply to recognize them as

traditions - historically and culturally situated; it is to recognize the

legitimacy of other traditions within their own terms. And it is to invite the

kind of dialogue that might lead to common ground.

Gergen believes that this view still allows modernist psychological perspectives

their place in psychology, but as one of the many narratives by which we explain

and structure our world.

30

Social constructionists place great emphasis on the intersubjective influence of

language, family, and culture on the construction of the meanings and metaphors

by which we live. From this standpoint, our traditions are sustained by a

continuous process of generating meaning together (Burr, 1995). This has

important ramifications for how we view the nature of madness/mental illness. If

realities are socially constructed, then the meaning of mental illness/madness is

to be found or generated in the social practices of our time, and cannot be

divorced from these practices.

3.3.2 Realities are Constituted Through Language

Perhaps the most pervasive impact that the postmodern social constructionist

worldview has on the social sciences derives from its use of interpretive

methodologies based on the model of language and discourse (Sey, 1999). The

so-called ‘linguistic turn’ of French philosophy, especially in the 1960s, brought

theories of reference and meaning sharply into focus again in a Western

intellectual world that had been dominated for over a century by positivism and

materialism in the social sciences, and by empirical theories of reference in the

human sciences. Under the impact of a rediscovery of the theories of ‘structural

linguistics’ of Ferdinand de Saussure, many intellectuals undertook a revision of

theories of reference and meaning, based on the central insight that objective

reality, individual consciousness and thought itself were all mediated by linguistic

structure (Sey, 1999). Saussure’s theory held that there is no natural or

necessary connection between objects in the world (referents) and the language

which refers to them and gives them meaning.

The idea that the connection between linguistic signs and meanings was a

conventional one rather than a natural or necessary one, had the profound

epistemological consequence for the social sciences of inverting the hierarchical

relationship between interpretation and its objects, thus prioritising interpretation.

As a consequence, interpretive strategies began to develop which operated from

31

the premise that cultures and their objects, products and practices were all

equally interpretable according to the model of the interpretation of texts, or,

more generally, narratives. It is from this movement that social constructionism

takes one of its underlying assumptions.

Social constructionism asserts that the language we use constitutes our world

and our beliefs. It is in language that humanity creates their views of reality. The

only worlds that we can know are the worlds we share in language. Furthermore,

language is not only a passive receiving of pre-existing truths but an active,

interactive process (Freedman & Combs, 1996). Language organised into

disourses has an immense power to shape the way that people experience and

behave in the world. Language contains the basic categories that we use to

understand ourselves, and affects the way we act as women or as men, and

reproduces the way we define our cultural identity (Burman & Parker, 1993).

When we talk about any phenomenon (our personality, attitudes, emotions, for

example), we draw on shared meanings. Burman and Parker (1993) state that

language produces and constrains meaning. Meaning does not, or does not only,

reside within the individual’s heads. Finally, social conditions give rise to the

forms of talk available. The exchange of language is a symbolic interaction where

we exchange and learn social conventions and rules (Babbie & Mouton, 2002).

In agreeing on the meaning of a word or gesture, we agree on a description, and

that description shapes subsequent descriptions, which direct our perceptions

toward making some descriptions and away from making others (Freedman &

Combs, 1996). As Vivien Burr (1995, p. 7) puts it: “When people talk to each

other, the world gets constructed."

This is in contrast with the modernist view that reality exists ‘out there’ and that

we can come to understand it through systematic enquiry. For example, in order

to understand the ‘reality’ of madness/mental illness, we would have to critically

explore the language used to describe or define it. Gergen (1999) states that

32

language tells one how to see the world and what to see in it. According to

Gergen speaking isn’t neutral or passive and every time we speak we bring forth

a reality. Each time words are shared legitimacy is given to those distinctions that

the words bring forth.

This brings into sharp focus the argument against the diagnosis of mental illness.

If our language shapes reality, then surely the language of diagnosis makes it so.

This approach to research makes it possible to critically explore the language

around madness/mental illness and how this influences practices of caring for the

mad/mentally ill.

3.3.3 Realities are Organised and Maintained Through Narratives

If the realities we inhabit are brought forth in the language that we use, they are

then kept alive and passed along in the narratives we live and tell (Freedman &

Combs, 1996). In effect, we identify ourselves through narration (Gergen, 1999).

Narratives help people make sense of their experiences such as joy and

sadness. People live according to these narratives (Morgan, 2000).

Modernism requires that narrative knowledge be subjected to the abstract

knowledge of positivism (Lyotard, 1984). In traditional African societies, for

instance, there is a rich tradition of narrative knowledge. During colonisation the

narrative knowledge of Africa was subjugated to the positivist scientist

knowledge. Where traditionally knowledge was transmitted in an oral, narrative

form and validated through social processes in African societies, modernism

requires a scientific validation of knowledge (Bakker, 1999). There lurks a

paradox in this, however.

The modern narratives that legitimise scientific knowledge are cultural products.

Science, including modernist psychology, is legitimised through appeal to grand

narratives (Kvale, 1992b). The dominant view of humanity in Western narratives

33

of legitimisation was constructed out of a rational self-image by philosophers

such as Plato, Aristotle, Descartes, Kant and others. Their philosophies have

become the grand narratives informing psychology. Their view of "man" as a

rational, self-determining individual has dominated psychology (Bakker, 1999).

A social constructionist worldview rejects such appeals to grand narratives

(Lyotard, 1984) or meta-narratives (Sey, 1999). This position implies that a

unifying social theory about people in the world is problematic, and proposes

rather that the diversity, multiplicity and different subjectivities be recounted from

the transparent perspectives of the researcher in culture and time.

3.3.4 There are No Essential Truths

In the social constructionist worldview, since one cannot objectively know reality,

all we can do is interpret and explore experience. There are many possible

experiential realities (Freedman & Combs, 1996; Gergen, 1999). As Freedman

and Combs (1996, p.34) very eloquently put it: “Within the multiple stories and

multiple possibilities of the narrative "multiverse" there are no essential truths."

Knowledge is seen as value laden and subjective and hence objective neutrality

is impossible. Social constructionism is critical of knowledge that is taken for

granted, as knowledge is sustained through social processes which are

constantly shifting (Doan, 1997). The world within which we exist is governed by

institutions that are socially constructed by its members over many generations

(Henning, 2005). These institutions are our society or culture, and they establish

the beliefs, practices, customs, and words that direct our behaviour and give

expression to our experiences (Henning, 2005). Reality is subjective as we view

it through the lenses bestowed on us by culture (Henning, 2005).

Social constructionism believes that there are certain dominating discourses in

society that are embedded in our language, which influence our perceptions of

34

the world (Doan, 1997). A social constructionist perspective is therefore

especially interested in the normative or grand narratives that are formed by and

in turn influence people, and against which people measure themselves. It is

partly through identifying the dominant discourses prevailing in our society and

challenging them that new meaning can emerge (Rapmund, 1996). This

worldview then leads us to explore the stories around mental illness/madness,

how they influence people to act toward the mentally ill, and how they are

measured by the society in which they live.

3.4 The Subject in Social Constructionism

The self is viewed as relational rather than individual. The self is a manifestation

of relationships, thus placing relationships in the central position rather than the

individual self of modernist worldviews (Gergen, cited in Becvar & Becvar, 2006).

The self, being predominantly relational, is therefore multiple, in that it is

comprised of the connections we create and sustain with the people,

experiences, and places that give our lives meaning (Harre, cited in Henning,

2005). An individual is therefore defined in terms of an ongoing flux of social

activity. His or her self and thoughts are actually social processes (Babbie &

Mouton, 2002).

3.5 The Role of the Researcher

In the social constructionist epistemology the perspective of the researcher takes

on a different significance. The stance of the researcher moves away from a

scientifically objective and detached observation of the positivistic position

(Wetherell et al., 2001) towards a more interpretive and reflexive orientation

(Lyotard, 1984). The argument here is that a basic feature of social research is

its reflexivity, namely, the researcher acts on the world and the world acts on the

researcher in a loop (Wetherell et al., 2001). If this is accepted, the researcher

35

moves to a central and visible position. Detachment is impossible so the

researcher’s influence must be taken into account and even utilised.

3.6 Conclusion

In this chapter the difference between the assumption of modernism, which look

to science to produce value-free, generalisable truths, and the assumptions of a

postmodern, social constructionist epistemology were explored. When adhering

to this approach, the function of research is to explore a particular version of

reality in an embedded context. Language is seen as the structuring aspect of

social reality; and as such, the only access researchers have to the social world

is through the language we use to describe it.

�

�

�

�

�

36

�������������

Methodology

Not everything that can be counted counts, andNot everything that can be counted counts, andNot everything that can be counted counts, andNot everything that can be counted counts, and

Not everything that counts can be counted.Not everything that counts can be counted.Not everything that counts can be counted.Not everything that counts can be counted.

Albert Einstein 1879 Albert Einstein 1879 Albert Einstein 1879 Albert Einstein 1879 ---- 1955 1955 1955 1955

37

4.1 Introduction

This chapter entails a detailed description of the research process used to

acquire information for this study. It presents information regarding the motivation

for selecting a qualitative research method and the implications thereof. It further

elaborates on the process of selecting participants and the process of data

collection. Finally, I discuss the phases of data analysis in terms of Parker’s

(1992) seven stage guidelines for discourse analysis.

4.2 Qualitative Research Design

The choice of a qualitative research design was motivated and informed by the

selection of the research topic. Qualitative research tends to be concerned with

meaning (Willig, 2001) and is therefore the method of choice in this study where

subjective meaning around madness/mental illness is explored. Qualitative

researchers tend to be concerned with the quality and the texture of experience,

rather than with the identification of cause-effect relationships (Willig, 2001). The

motivation for this approach was also stated succinctly by Kvale (1996, p. 44):

“knowledge is neither inside a person nor outside the world, but exists in the

relationship between person and world”. This is in keeping with the social

constructionist principle that knowledge is created between people through

interaction and language. Thus the theoretical framework for this study

incorporates the subjective nature of reality and views of our worlds as

multiverses that we co-create and reconstruct through observation (Durrheim,

1999.

4.3 Sampling and Participants

Holstein and Gubrium (1995) see participants, in postmodern research, as

capable of the production of “representative horizons of meaning” (p. 74) as

opposed to being selected as a valid and reliable representation of a sector of

the population.

38

Four participants were selected through purposive sampling, although the final

number depended on the saturation of themes. The requirements for

participation in this study were defined as follows:

Participants must be between the ages of 23-30. This age group was selected

based on the assumption that participants would likely have finished tertiary

education and would be in the early stages of building a professional career. In

developmental terms, young people in this age group have a relatively well-

formed idea of what it is that they believe. Having had time during adolescence

and tertiary education to shape worldviews, in this stage they start living

according to those beliefs while starting a new career, entering into relationships

with others with more or less the same views, and so on. The moratorium society

allows its youth to grapple with the many different meanings of society, and to

carve their own unique belief system is over by the time young adults enter the

work force (Hughes, 2002). Meanings around madness/mental illness should be

relatively fixed and start influencing how young adults act towards the mentally ill.

As such, these views are a “representative horizon of meaning” (Holstein &

Gubrium, 1995, p.74) of the views of the economically active population.

Participants must have finished at least a tertiary degree. The assumption

informing this decision is that the education received at tertiary level may

broaden the meaning field of individuals and provides more extensive knowledge

on social issues. Another assumption is that the critical thinking that is a

secondary focus of tertiary education should provide people with a tool for

evaluating social information.

Participants must not have had formal contact with the mental illness discourse

as their meaning world would inevitably be partly shaped by this discourse. One

of the aims of this study is to explore the constructions of those not involved in

the ‘madness as mental illness’ model in order to explore broader influences and

positions around this discourse. This lack of contact includes no personal or any

39

close family contact with mental patients or the institutions responsible for their

care. This then excludes, for example, any persons that have studied psychology

or medicine as part of their tertiary degree.

The participants of this study can be described as follows. Annabelle is a 25

year-old Afrikaans-speaking primary school teacher who lives with her fiancé.

Nadia is a 26 year-old Afrikaans-speaking auditor who is engaged but lives with a

friend. Ryno is a 25 year-old Afrikaans-speaking senior developer for an IT

company, and Kegan is a 26 year-old Afrikaans-speaking business unit manager.

They requested to read the discussion of the results and I agreed to send all the

participants copies of the final text.

4.4 Data Collection

4.4.1 Participant Interviews

The semi-structured interview gives the researcher the opportunity to hear the

participants talk about a particular aspect of their life or experience (Willig, 2001).

This style of interviewing is sometimes described as non-directive although it is

important to remember that the research question drives the interview. A

carefully constructed research agenda can help the researcher to stay close to

and not lose sight of the original research question (Willig, 2001). The main

advantage of a semi-structured interview is that it gives in-depth data on the

question being investigated (Struwig & Stead, 2001).

According to Kvale (1996), interview schedules should not focus on specific

standardised questions but rather on themes, as this allows for openness and the

unexpected. The themes for the interviews were:

• What does it mean to be in a psychiatric institution?

• What are the possible causes for this?

• How should these people be treated”

40

• What are the participants’ personal views on contact with patients from

psychiatric institutions?

• Who can become mad/mentally ill?

• What has shaped the participants’ views on madness/mental illness?

The introduction of words describing mental suffering was guided by the words

used by the participants, as was the introduction of themes. The interviewer met

the participants in locations of their choice so that the participants could feel

comfortable. Interviews lasted 45 minutes to one hour.

4.4.2 Recording and Transcribing Interviews

According to Edwards (1998, p.42), “careful and unbiased description is essential

when investigating a new or little researched phenomenon”. Mahrer (1988)

recommends that to study a phenomenon, researchers should obtain instances

of the phenomenon in the form of video or audio tapes of therapy sessions. For

this reason the interviews were carefully recorded using audio tapes after

informed consent from participants was attained.

In Kvale’s (1996) discussion of transcripts, he points out that transcripts are an

artificial creation of a different medium of communication. Certain complications

in the transcription of interviews arise. Conversations have a different rule system

than written language and this being the case, information can be lost when

translating from oral to written form. Kvale (1996) thus sees transcripts as

interpretive constructions of reality and not copies or representations thereof. As

transcripts are a representation of the original interviews, they are no longer the

original data and information is lost in the process of translation from oral to

written. Despite this, it is important to keep in mind that the transcripts are not the

focal point or topic of the study but rather a means by which the interviews are

interpreted. An awareness of the interpretive constructions of the transcripts may

41

play a role in preventing the possible reification of analysis of the text (Kvale,

1996).

While carefully transcribing the interviews, I reflected on my part in the creation

of the text by adding these reflections to the text in the margin. The aim of this

was to maintain reflexivity on my part in accordance with the social

constructionist underpinning of the study.

4.5 Data Analysis

4.5.1 Discourse

One of the key concepts in social constructionism is discourse. A discourse is a

regulated set of statements which combine with others in predictable ways (Mills,

2003). Discourse refers to a new way of understanding language (Wetherell &

Potter, 1988). It involves an understanding of “language as the basis of thought

and selfhood, about the multiplicity of meanings inherent in any piece of text or

speech, and about how this leads us to consider personal identity as temporary,

fragmented and open to question” (Burr, 1995, p.46).

One of the most important implications for research is the view of a discourse as

constructive in nature. A discourse does not merely represent reality, but actively

produces the social entities and relationships we conceive of as being part of that

reality (Fairclough, 2003). Discourse analysis conceptualises the relationships

between the individual and the social, the cultural, and experience in general, as

being largely discursively patterned (Painter & Theron, 2001). According to

Painter and Theron (2001, p. 4), ”both the hold that a form of life attains over

people’s self-understandings and behaviours, and the powers they have to

challenge those discourses or representations that help sustain their forms of life

– especially when these are oppressive – are theorised on the level of discursive

processes.”. This implies that discourses position people in certain social

42

positions. As such, all discourses actively construct their objects in certain ways

(Gergen, 2001).

The aim of this study is to explore and identify the discourses around

madness/mental illness. In the work of Foucault, the term ‘discourse’ refers to

alternative ways of arranging areas of knowledge and social practice.

(Fairclough, 2003). According to Burman et al. (cited in Painter & Theron, 2001,

p. 2), the object of discourse analytic research is to tease out the “structuring

effect of language, and of connecting institutional power relations with talk”.

Based on the Foucauldian view of discourses (cited in McHoul & Grace, 1998),

there are several clearly observable components thereof. These are objects,

operations, concepts and theoretical options. That which is being studied is the

object. In the case of this study the object is the mental departure from the social

norm and is variously described as madness, metal illness and so on.

Operations refer to the various ways of treating these objects (McHoul & Grace,

1998). The theoretical options are the different theoretical underpinnings

available to the study, which in this case refer to the social constructionist

epistemology underpinning this study; and the concepts are the regularly used

terms that form the unique language of a particular discipline (McHoul & Grace,

1998). Foucault further identifies certain characteristics of a discourse: the rules

that make the formation of objects and concepts possible (formation), the

relationship a discourse has with other discourses (correlation) and the ways in

which the discourse can modify itself and the limits to such a modification

(transformation). These concepts provided the basis for my understanding of

discourse.

The approach to discourse analysis used in this study focuses on the set or

family of terms which are related to the specific topic of madness/mental illness.

This approach draws attention to how new terms enable people to talk about

different things; but this is not simply a matter of attaching different labels to

43

already existing objects. It also addresses the sense that language is

constitutive, it creates what it refers to. Meanings are created and eroded as part

of ongoing social change. This approach understands language as situated

within a particular social and cultural context rather than only within a particular

interaction (Wetherell et al., 2001). This approach is in keeping with the social

constructionist epistemology that forms the underpinning of this study.

Another important characteristic of a discourse is that discourses are not neutral,

but are embedded in power relations (Burr, 1995). Even though discourse

analysis gives primacy to language as structuring psychological phenomenon

and subjectivity itself, it never pretends that this takes place in an environment

where relations of power are not materially institutionalised and imposed (Painter

& Theron, 2001). The type of knowledge available in society is intimately bound

up with the powerful discourses in that society. Importantly, this power resides

not in individuals or groups, but in discourse which individuals and groups tap

into (Burr, 1995). The goal of discourse analysis is to deconstruct dominant

discourses and representations that sustain certain oppressive power relations

(Painter & Theron, 2001). Marginalised and repressed voices within these

discourses are important ways of challenging dominant discourses (Foucault,

1972).

The discourse on madness now falls within a predominantly medical arena. It is

seen as an ‘illness’ and something that can only be ‘cured’ by relevantly trained

practitioners. This immediately constructs the mad in a position of

powerlessness. As I am situated in a powerful position within this discourse,

namely, I am an intern clinical psychologist who is charged with ‘curing’ the ‘mad’

of their ‘illness’, I have become profoundly aware that there are many different

voices involved in the discourse on madness that have specific implications for

how subjects (people the discourse relate to) are positioned around the object of

the discourse, and that imply certain power relations; however, I am also

44

profoundly aware that these have not received the attention of psychological

inquiry.

4.5.2 Procedure

In order to explore the meanings of madness/mental illness in a group of young

professionals, I conducted a discourse analysis. No single method exists for

conducting a discourse analysis. Keeping in mind the characteristics of a

discourse discussed above, I made use of the method which is outlined by Ian

Parker (Parker, 1992). Parker describes a discourse as “a system of statements

which construct an object” (Parker, 1992, pg. 5). Parker’s method refers to seven

criteria necessary for distinguishing discourses, as well as three additional

criteria relating to power, institutions and ideology. Each criterion has two

components. During the data analysis I did not follow Parker’s method as it is

indicated. Instead I used the concepts of Parker’s method to inform the way I

read the text and to inform how I structure and understand it. In the analysis,

particular attention was given to how mental patients are constructed in the

various discourses identified. Parker’s criteria are expounded below.

1) A discourse is realised in text

During research we never find whole discourses (Parker, 1992); instead, we find

pieces of discourse which are embedded in texts. Texts are any thing which can

be interpreted (Parker, 1992). Included in this category are transcripts on

interviews and conversations. To begin with, we need to specify the text we are

studying. Therefore, the first two components are:

1) Treating our objects of study as texts which are described, put into

words

2) Exploring connotations through some sort of free association, which is

best done with other people

45

2) A discourse is about objects

Parker (1992) differentiates two layers of objectification. Firstly, there is the

‘reality’ to which the discourse refers. By referring to something, a discourse

brings it into reality (Parker, 1992). The object, therefore, comes to be constituted

in and by the discourse (Parker, 1992). The second layer of objectification or

‘reality’ to which the discourse refers is itself (Parker, 1992). Therefore, the

discourse takes itself as an object (Parker, 1992).

As such, the next two components are:

3) Asking what objects are referred to, and describing them

4) Talking about the talk as if it were an object, a discourse

3) A discourse contains subjects

Even if objects do have another reality outside of the discourse, they are given a

new reality by the discourse (Parker, 1992). Discourses as such make available

spaces for a particular type of person – a particular self (Parker, 1992). The

components concerning this criterion are:

5) Specifying what types of person are talked about in this discourse,

some of which may already have been identified as objects

6) Speculating about what they can say in the discourse, what one could

say if one identified with them (what right does one have to speak in

that way of speaking)

4) A discourse is a coherent system of meanings

Together, the metaphors, analogies and pictures of a discourse can be drawn

together into a coherent set of statements about the reality it is describing

(Parker, 1992). The next two components in conducting a discourse analysis are:

7) Mapping a picture of the world the discourse presents

46

8) Working out how a text using this discourse would deal with

objectifications to the terminology

5) A discourse refers to other discourses

In the simplest sense, in order to speak about discourse we have to employ other

discourses (Parker, 1992). Metaphors and so on from other discourses are

always available to speak of a discourse (Parker, 1992). Often, these will come

about as a result of contradictions within and between discourses (Parker, 1992).

Therefore different discourses are always interrelated.

Components nine and ten look at these relationships:

9) Setting contrasting ways of speaking, discourses, against each other

and looking at different objects they constitute

10) Identifying points where they overlap, where they constitute what

looks like the ‘same’ objects on different ways

6) A discourse reflects on its own way of speaking

At some point, most discourses comment on themselves (Parker, 1992). There

are various layers of meaning within discourses (Parker, 1992), some of which

are rarely voiced but which nevertheless form part of that discourse (Parker,

1992). The two components associated with this criterion are:

11) Referring to other texts to elaborate the discourse as it occurs,

perhaps implicitly, and to address different audiences

12) Reflecting on the terms used to describe the discourse, a matter which

involves moral/political choices on the part of the analysts

47

7) A discourse is historically located

Discourses are not static but constantly change and overlap (Parker, 1992).

Therefore we must locate the object in time (Parker, 1992). To do this the analyst

must:

13) Look at how and where the discourses emerged

14) Describe how they have changed, and told a story, usually about how

they refer to things which were always there to be discovered

8) Discourses support institutions

Discourses are used to support certain institutions and their practices (Parker,

1992). Therefore the following two components are suggested:

15) Identifying institutions that are reinforced when this or that discourse is

used

16) Identifying institutions that are attacked or subverted when this or that

discourse appears

9) Discourses reproduce power relations

Discourse and power are intricately bound (Parker, 1992). The next two

components are:

17) Looking at which categories of person gain and lose from the

employment of the discourse

18) Looking at who would want to promote and who would want to dissolve

the discourse

Within discourses

10) Discourses have ideological effects

The two components associated to this criterion are:

48

19) Showing how a discourse connects with other discourses that sanction

oppression

20) Showing how discourses allow dominant groups to tell their narratives

about the past in order to justify the present, and to prevent those who

use subjugated discourse from making history

4.6 Ethical Considerations

Wassenaar (1998, p.140) points out that “with the growing national and

international diversification of psychology, no single code of ethics will anticipate

all of the contexts in which psychologists will work, particularly in a rapidly

changing South Africa”. In such a context, researchers are compelled to engage

the field of ethics in a dynamic and personalised manner, so that the researcher

'is the ethics' (Snyman & Fasser, 2004). In order to 'be the ethics,' the

researcher should self-monitor. This means that researchers should take

cognisance of every research encounter and the ethical implications of every

research dialogue (Snyman & Fasser, 2004).

Some of the basic ethical considerations towards participants are summarised by

Willig (2001). These include:

• Informed consent: The researcher will ensure that participants are fully

informed about the research process and give their consent to participate.

• No deception: Deception of participants should be avoided altogether.

Participants should be fully aware of the aim and purpose of research.

• Right to withdraw: The researcher will ensure that participants feel free to

withdraw from the study should the need arise.

• Debriefing: The researcher will ensure that, after data collection,

participants will have access to any publications arising from the study

they participated in.

49

• Confidentiality: The researcher will maintain complete confidentiality

regarding any information about participants acquired during the research

process.

These ethical considerations have been followed throughout the study. I have

also tried throughout my interaction with participants to ‘be the ethics’ as Snyman

and Fasser (2004) have suggested, by keeping track of my own interaction with

the participants.

4.7 Conclusion

This chapter discussed the methodological underpinnings of the study and how it

was implemented during the data collection and analysis. The choice of a

qualitative research paradigm was discussed along with the implications of such

a research design. Parker’s (1992) method for conducting a discourse analysis

as used in the analysis of the interview data was discussed, and ethical

procedures followed in the study were explained.

50

�������������

Results of the study: discourse

analysis

And, if they’re said with the right passion and the gods are bored, And, if they’re said with the right passion and the gods are bored, And, if they’re said with the right passion and the gods are bored, And, if they’re said with the right passion and the gods are bored, sometimes the universe will reform itself around words like that. sometimes the universe will reform itself around words like that. sometimes the universe will reform itself around words like that. sometimes the universe will reform itself around words like that. Words have alwaysWords have alwaysWords have alwaysWords have always had the power to change the world. had the power to change the world. had the power to change the world. had the power to change the world. Terry PratchettTerry PratchettTerry PratchettTerry Pratchett Soul MusicSoul MusicSoul MusicSoul Music

51

5.1 Introduction:

According to Parker (1992), we never find whole discourses during research;

instead we find pieces of discourses embedded in texts. During the analysis of

the interview transcripts used as the texts for this research project, a number of

differing discourses were identified.

These discourses were: The scientific discourse of mental illness; mental illness

as the domain of professionals and mental institutions; mental illness as

individual experience; mental illness as unknown; and mental illness as bad.

In this chapter these discourses are discussed in terms of how they construct

those with a mental illness and those without a mental illness. Similarities and

differences between the discourses are highlighted.

5.2 Scientific Discourse of Mental Illness

In this discourse mental illness is given a scientific explanation and those with a

mental illness are constructed as suffering from a medical condition,

psychological problems, or a combination of the two.

When we turn to the medical discourse, patients are constructed as having a

genetic abnormality that is to be found in their families, as is evident in the

following statement:

“Obviously something went wrong somewhere along the line, I

don’t know if it was genetic or if their families maybe

somewhere in the bloodline have this sort of thing in their

background.”

This view sees those with a mental disorder as being inherently defective, and

mental illness is confined to that individual. This discourse constructs patients as

52

‘other than’ the normal population; they are not the same as those without a

mental illness:

“…and obviously people that were born like that. That, um, like

with only, born with a defect or something. Like Down’s

Syndrome.”

Those without a mental illness are positioned in this discourse as healthy

individuals who do not have the genetic defect that leads to mental illness or

madness. They therefore have no genetic predisposition that leads to the

experience of mental illness. This position is maintained by describing

themselves as different from those who have such a defect and represents a

technique to distance themselves from people who have a mental illness as the

result of a genetic abnormality and their families:

“…,but it’s not in my genes, I know or obviously I think. OK

because we don’t have it in our family.”

The medical discourse also constructs mental patients as experiencing a

chemical imbalance that causes them to behave differently from those who do

not have an imbalance:

“Well I don’t know, it’s obviously a chemical imbalance.”

Mental patients as such have very little power to control their lives and

experience. If they are constructed as having a medical illness the only treatment

for this is medication:

“…it’s something that affects you and that you can’t fix

yourself without medication, I see it as an illness.”

53

“Deeper…medication. He needs science.”

Furthermore, it is not constructed as a passing affliction but rather as a chronic

problem that needs to be managed with medication:

“…it’s a chronic illness I think. It’s something they have to live

with.”

In this way mental patients will never be healed and will remain ill although

medication may keep their condition under control. This idea overlaps with the

discourse of mental illness as bad. (This discourse is discussed below.) If mental

illness is a chronic affliction that can only be managed on medication, then the

only responsibility of the mental patient is to continue taking this medication on a

regular basis. When medication is stopped by the bearer of the condition (as is

quite possible from the perspective of those without a mental disorder), then they

will relapse into the illness and it will make treatment more difficult for the

professionals who are in charge of their cure:

“…then they are in an even deeper hole than they were,

because then they have maybe been without medication for so

long and then the medication doesn’t work anymore and then

they need other medicine, ten to one.”

If those who do not act according to the social norm are constructed as suffering

from a medical defect, then those who do not have such a defect easily

subscribe to the construction of a professional medically trained person or

personnel who need to treat these patients by medical means. The above quoted

text represents the participant’s firm belief in the medical explanation of mental

illness. As such, healthy individuals do not have to take responsibility for treating

these individuals, as they do not have the necessary skills. This represents

another distancing technique employed by those who do not have a mental

54

illness. Pleading ignorance of the scientific explanation of mental illness

successfully exempts the participants from any responsibility in the care for the

mentally ill:

“…but I don’t know, I don’t have scientific training…”

This position overlaps with the position of those who do not have a mental illness

in ‘the mental illness as unknown’ and the ‘mental illness as the domain of

professionals and mental institutions’ discourses. In these discourses, as in the

discourse above, the participants adopt an outsider’s position in the discourse as

not having the necessary expertise to understand the experience and treatment

of mental illness. They are also comfortable with this position, as can be seen

from the techniques employed to distance themselves from those with mental

illness.

This discourse constructs mental health practitioners such as doctors and

psychiatrists as the experts. They have the relevant knowledge about medicine

and medical causes of illness and they are charged with the cure of those who

are mentally ill. As such, they are not only talked about in this discourse but also

have the most power to talk, whereas those with mental illness become the

object of treatment and those not without mental illness remain outside

observers. As such, they are therefore also powerless in this discourse and can

only comment on it from the outside.

The family of the mental patient also remains on the outside of this discourse.

Although they are constructed as wanting to care for their relative and wanting to

help, they are powerless to do so:

“…know love, love doesn’t fix everything in my view. If you

think you care for the person and he will come right, no shit

55

man, there’s deeper, a deeper illness that Med Lemon can’t

fix.”

Some of the metaphors used to speak about this discourse come from the

medical model of illness with doctors as treating professionals and medical

intervention such as medication and operations:

“I just go back to what is familiar to me. If you go to a doctor

and you are ill they normally treat the symptoms…”

“…if you ask me about the treatment then I think of normal

doctor treatments that you can link back.”

The second scientific explanation of mental illness is that such individuals also

have psychological problems. In this discourse mental patients are constructed

as the victims of very difficult life circumstances such as physical and sexual

abuse, and the intense emotion that go with these experiences:

“It depends what emotion it is. Is it pain, what emotion and the

strength that abuse came to the fore with.”

Appealing to this discourse, those who have mental illness are constructed as

deserving of sympathy as they have suffered much in their lives. This discourse

allows for more identification with people who have experienced emotional and

physical abuse by those who have not experienced it. Those who did not

experience this abuse are construed as having a moral responsibility towards the

former, if they are to be good people. This is because the possibility of

experiencing terrible events that can disturb one to the point of madness can

happen to anyone:

56

“I think it can happen to anyone. Um…yes, it only depends on

the intensity of what happens…”

“And I think if something happens in your life you stand a

chance that it will happen to you. So that is how I feel about it.

So I think anybody can uh, stands a chance.”

Even though the participants could understand and identify with escaping from

difficult life circumstances into madness, the idea persists that non-sufferers are

not the same as those who have a mental illness. They are the lucky ones who

have not suffered these horrid life circumstances; they are the survivors of the

onslaught of life; and this safeguards them from the possibility of developing a

mental illness. As such, even though they appear to identify with these people

they also distance themselves from them:

“I think my circumstances are different. If I had different

circumstances then I could also have ended up there.”

After a traumatic event, some people deal with ensuing emotions by withdrawing

into mental illness. Mental illness is thus seen as the way some people deal with

life events, which implies some sort of intentionality: they are not only passive

receptors or sufferers of medical conditions:

“If you as normal person, you get taken out of your comfort

zone and then you develop something mentally, and then you

create your own little world one can basically say.”

Treatment for mental illness does not lie in medication but in the help of

psychologists who can assist mental patients to work through these emotional

difficulties in various ways. In this discourse, as in the medical discourse

discussed above, mental patients remain powerless and cannot really speak

57

about their experience, unlike psychologists, who have the necessary expertise

to help them. Some of the ways in which professionals can treat people with

psychological problems is by building a relationship of trust:

“So some or other relationship of trust if it is possible to help

them with enough confidence that it can help with their healing

process.”

Psychologists can also teach afflicted individuals how to behave differently. This

idea draws on learning theory that explains all human behaviour in terms of

learned impulses and reaction to life events:

“…but like any other problem, like bad habits or switching a

light switch on and off twenty times, and you learn not to. It’s

like quitting smoking.”

In the same way these behaviours can be learned by mental patients as they

interact with other mental patients:

“And maybe you will get worse and you will…I think if that

person is worse than you, then you will definitely learn it…”

Within this discourse, medication and the intervention of psychiatrists is seen as

misguided; and fails to treat the cause of the problem:

“I also think medication is just something to suppress the

person’s instability or to suppress the person’s condition.”

A reflection on the medical model of mental illness, where illness is caused by a

genetic defect or a chemical imbalance, and the view of the mental illness as

being due to psychological problems, reveals various contradictions between the

58

two discourses. In the first, those with mental illness are constructed as having

an inherent defect that positions them in a definite place of being ‘other than’

those who do not have these defects. In the ‘mental illness due to psychological

problems’ discourse, those with a mental illness have experienced something

that it is possible for anyone to experience. In the discussion it appears as if

these two discourses stand apart from each other, but in the text there is

considerable confusion about which of the two discourses and which of the two

constructions surrounding mental illness is dominant. Respondents move from

one to the other in an unstructured, erratic way; and this reflects some confusion

around the understanding of mental illness and its causes by those who have no

contact with these discourses:

“I think the genetic one. It doesn’t mean that because your

mother had it that you are going to get it also, not definitely,

but if the circumstances are of such a nature, say you have

had a traumatic experience or something, then you are more

prone to lead to depression that the person next to you that

maybe does not have it, that maybe does not have the genes.”

These two discourses are subsequently combined in the construction of mental

illness and those who have a mental illness. People without a mental illness

seem to distinguish between genetic, medical causes of mental illness and

psychological causes, but also acknowledge an interaction between the two:

“So I think, I think it is inherent, I think it is genetic, but I think

the people around you and the support network certainly has

an influence on it.”

“It I think can be genetic…I think it can be like a genetic

defect. Then I think it can be abuse, I think it can be external

factors.”

59

Exactly how these different explanations or causes interact is not so clearly

defined by those outside the medical or psychological discourse; and there is

some confusion about these causes. In this way this discourse supports the role

of mental health practitioners as experts, and constructs them as the most

powerful players in this discourse both as those who have the most potential to

speak and as those with the most knowledge about and power to heal those with

mental illness. As such, this discourse also supports institutions of learning that

educate these professionals in the art of curing those afflicted by mental illness,

and support the scientific biopsychosocial model of madness as a mental illness

that can either develop due to medical causes, emotional causes or an

interaction of the two. This discourse also constellates a multidisciplinary

treatment team, with psychiatrists who treat with medication, psychologists who

provide psychotherapy, and so on.

This discourse also draws on the modernist tradition that assumes that mental

illness is a static objective truth; and assumes that the correct cause can be

identified and treated through careful examination. This discourse assumes that

mental illness is inherent within the individual, and as such, correlates with the

Western view of madness as mental illness.

Absent form this discourse are spiritual explanations for mental illness such as

those provided by the church in earlier centuries. There was no mention of

possible possession or witchcraft, as explained in African culture. As such, the

church, spirituality and culture have no significant place in this discourse. It

places on the periphery and strips of power those explanations that do not fit

within the scientific worldview. In this way, people with mental illness who do

employ these explanations will be marginalised by this discourse. This has the

implication that some of the cultures in our

South African society will feel even more powerless when they find themselves in

this environment. Not only are they already suffering from subjectively difficult

60

experiences but the explanations they employ in order to understand these

experiences will be marginalised by those who they seek help from.

This discourse overlaps with the discourse of mental illness as the domain of

professionals and professional institutions that will be discussed in the following

section.

5.3 Mental Illness as the Domain of Professionals and Mental Institutions

In this discourse mental illness is seen as the domain of mental health

professional and the institutions in which they work. People who have a mental

illness are constructed as needing help from others because they cannot function

normally and are in need of containment by those from whom they seek

professional help. Mental health workers are charged with the responsibility of

the care of these patients; and psychiatric institutions are the place where they

go to be cured and housed while they are under the supervision and treatment of

professionals.

In this discourse people with a mental illness are only talked about but have no

power to talk for themselves. This is the role of the trained professional who can

understand what it is the individual is experiencing:

“…you know, qualified decision made about, about which

treatment…”

“… but if someone that obviously has the competence to make

that decision…”

Decisions about whether people need treatment, the kind of treatment they need,

and whether they need to be institutionalised, all lie in the hands of the mental

61

health professional. As such, patients have no power to make decisions

regarding their own treatment and confinement:

“I don’t think necessarily they are fit to decide which treatment

they get.”

The participants acknowledge that institutionalisation must be an anxiety-

provoking event for people with a mental illness. They perceive it as a negative

experience:

“You know ten to one it is precisely how those people feel

when they go to the hospital. The patients. You know and I

think that is how we would feel, I would feel if I walk in there.

Definitely you don’t know what’s gonna happen with you.”

“…because I think an institution is already emotionally difficult

for you…”

The participants constructed people with a mental illness as being incapable of

looking after themselves and not being able to live in normal society. This gives

the mental health practitioners the moral right to institutionalise them.

“I think because they cannot function on their own and they

need help.”

“…the best for Pietie is actually to have a place where

qualified people can look after him and where he can make

little friends.”

In the above text mental patients are construed as child-like in their needs and

abilities. The mental patient must go to the institution to make friends and be

62

cared for. Nothing like adult expectations are expected from these patients.

Among the participants chosen for this study none have any experience in caring

for dependants and feel ill-equipped to make the relevant decision if such a

situation arises:

“I have not been in a situation to say: Listen I am not going to

look after Pietie anymore,” or “I have to look after Pietie”. So I

cannot say it’s right or it’s wrong…

Within this frame, it is easy to abdicate the responsibility of looking after the child-

like and the dependant to professionals who know what they are doing. Again,

the idea of difference arises between those who do not have a mental illness and

those who do. If the latter are seen as child-like and unable to make decisions

about their lives, the participants are the opposite. They all have the ability to

make good decisions about their lives, do not need others to look after them and

can function in an adult capacity in society.

Mental patients in an institution are seen as passive, as is evident in the following

statement where they are compared to people in an old age home:

“People in pajamas, that are normally locked up for a large

part of the day and that are in group discussions, group

sessions and suchlike. I actually don’t think…almost like

people in old age homes. Just people that sit around.”

Even though mental patients have no say in what treatment they receive they are

constructed as having to ‘buy into’ the treatment in order for it to work. It seems

that the responsibility for the choice of the treatment lies with the professional,

but if treatment fails the fault lies with the patient. In this way the treating

professional is exempt from all responsibility and only carries the honour of being

the one with the sought-after knowledge to manage the problem:

63

“But um the people must definitely buy into it.”

“You must make the decision yourself, you know, I am gonna

change my being…”

Those who do not have a mental illness are also marginalised by this discourse

and excluded from it by the construction that it is professionals with specialised

training who are, firstly, able to identify and secondly, able to treat mental

patients. The participants as laypersons are constructed as non-experts,

powerless to intervene and help those with a mental illness:

“You know, I don’t know what treatment they get and what

medication they get and that type of thing…”

“…but I don’t think any man on the street will be able to walk

into a hospital and then give assistance.”

“You don’t understand it, even if you want to, you can’t help

them. Physically your hands are tied…”

Even though the community may have an interest in helping and understanding

people with a mental illness, they are unable to and they remain powerless in the

face of professional knowledge. By saying that they would not be able to help,

the participants also create distance between themselves, the treating

professionals and mental patients. If they then do not want to help, they are

employing a logical argument that supports their non-involvement in the

treatment and support of the mentally ill. This allows them to remain distant while

also exonerating them from blame for not caring.

64

The family of the patient is constructed in a supportive role only. They need to

retain contact with the patient in order to provide support for the treatment the

patient receives:

“…I think if the person still has people or ten to one family that

he is accustomed to, then it will be good to have contact with

those people”

“…so that if they are released from the hospital in the end that

they can go into society and still have someone that supports

them emotionally”

Very prominent in this discourse is how the different objects are constructed in a

less than favourable light. The institution as seen by those on the outside – the

man on the street – is invariably described as a clinical place where the patients

are locked up by the staff in white buildings in small rooms, almost like a prison:

“You see these white buildings with, again, white suits, and

the people in their small rooms just sitting.”

“You think it’s a clinical place and then you think the people

are locked up…”

“…a lot like a boarding house setup, certain sleeping times,

lights out um…people were one-one in a room and some of

their doors were locked…”

The treating staff is constructed as uncaring and unfeeling in their methods to

subdue and manage patients. They also use ruthless means to discipline

patients:

65

“…and they put him in this small confined space, cage-thing,

with his straitjacket or with his white suit and um…it looks as

if they just leave the people there.”

“…and then they give shock treatment…”

This constructs mental health practitioners not only as the lofty experts but also

as those who abuse power and do not really cure those suffering from mental

illness:

“…but I am still under the impression, you know, are people

really cured there?”

There is a strong overlap with the discourse of ‘mental illness as bad’ in these

constructions; and this is discussed more fully later on in this chapter. Both the

patient and the mental health expert are constructed as ‘bad’ in this discourse.

Mental patients are seen as child-like, unable to care for themselves, and

somewhat of a burden; and mental health professionals are seen as the

uncaring, ruthless wards of their child-like charges. Discursively the participants,

as people without a mental illness, feel obliged to justify this construction of

mental health professionals and as such plead ignorance of the discourse:

“So I think you don’t really understand why people go there.

But you know that’s my perception.”

They also blame the media for creating unsatisfactory images as their only

contact with the discourse:

“Again, you know, you, and ten to one the TV is the wrong

thing to use, but it is the only…It’s the only exposure that you,

66

if you didn’t have it in your family and you have not read or

studied about it, then it is the only exposure you get.”

In this way people without a mental illness can abdicate responsibility of the care

and treatment of mental patients to professionals, and can also rationalise any

bad constructions of those professionals as the result of skewed media portrayal.

They therefore do not have to assume any responsibility even though they have

some idea of mental health professionals as ‘bad’ and inefficient.

Importantly, the discourse on mental illness as the domain of mental health

practitioners and institutions overlaps strongly with the scientific explanations of

mental illness. It seems that when mental illness is constructed as having a

scientific explanation it gives mental health professionals the responsibility and

the power to treat individuals without their consent or even input, no matter how

controversial and shocking the means of treatment. As such, the community,

family and the individuals themselves have very little voice or power in these

discourses.

5.4 Mental Illness as Individual Experience

This discourse speaks about mental illness as an experience that only those

people with a mental illness can fully understand. Mental patients are constructed

as living in their own world that differs from normal reality, and that they seem to

experience as the proper reality. Those who do not have a mental illness have no

access to them and also cannot understand their differing reality.

The most important construction in this discourse is mental patients live in their

own world:

“…you know they are in their own little world, by themselves.”

67

“…but you know their perception of life and you that sit next to

them, across from them is not the same as yours. Their

windows look a bit different than yours.”

There is a sense that mental patients do not understand or experience that their

reality is different from the norm at all; and that they experience their own world

as normal and society as abnormal:

“…because they are normal and we are the weirdoes. I think

that is how they also see us.”

This throws into sharp relief the social constructionist argument that reality is

created through interaction and language; and the participant above reflects on

the possibility that a different reality is created by people with a mental illness.

Despite the fact that people with a mental illness create their own world and

seem to feel comfortable in this new world, there is also a sense that they are

isolated. If they create a world of their own, they lose contact with loved ones and

also greatly minimise the possible contact they can have with others, as very few

people share their reality. According to this discourse, they seem to isolate

themselves totally from others:

“…on the wall that that guy built around his life.”

“Dark and alone.”

Not even the love of family members can really penetrate their isolation and, in

some cases, despair:

“…there are people around them, but they don’t think so…”

68

“…love can only penetrate the outside. You know the person

feels love, but inside he still has that pain. You know. It

doesn’t go away.”

This constructs the subjects in this discourse – those without a mental illness –

as being in a powerless position when confronted with people who have a mental

illness. They cannot understand and they cannot help. It also leaves them with

very limited speaking power as they cannot gain access to the private world of

the mental patient:

“Because if they can’t help themselves then I won’t be able to

help them. Me and the common people on the street.”

In some instances the mental patient becomes the object of envy because they

have the capability to create their own world. They do not have to face the

negative aspects of society at large. There is an attempt to identify with those

with a mental illness. This becomes prominent in South Africa where a large

number of our society is very preoccupied with their own safety due to the crime

rate:

“They are so bloody happy and in a certain way I will actually

think they are lucky, because they are totally out of these

worldly circumstances. They are totally away from the norm

and we worry about murder and lock our gates and go wild.

They don’t worry about it. They live carefree.”

As discussed in the literature survey, psychiatrists such as R.D. Laing (1965)

have argued that psychosis enables the sufferer to escape intolerable

psychological pressures exerted by uncaring societies. The construction of

mental patients as creating their own little world to escape the horrors of this one

69

falls into this discourse. They do not have to worry about their safety and can live

a carefree life.

Even though the different reality is envied by those on the outside it also opens

mental patients to ridicule as they are seen as acting in a way that is different

from others:

“I think you giggle about it but don’t really realise it’s a

problem and you don’t really do something else about it other

than it is only weird for you and you giggle about it, probably.”

In this discourse the role of the family and those who do not have a mental illness

is to maintain contact with mental patients to bring them back to the normal

reality. This is then also the function of mental health professionals:

“…you know and I also think the people in hospital should

have contact with other normal people that they also have.”

“…people must… one, the person, one must first feel

comfortable with his surroundings and I think slowly and

systematically the person must be exposed to reality again.”

Although this discourse constructs mental patients as the experts of their

experience, it nonetheless also places them in a position of powerlessness in

society as a whole. If they do not access the same reality as normal society they

cannot contribute to societal life. This justifies institutionalisation and the

intervention of medical professionals who can help them regain their grip on

‘normal’ reality.

People without a mental illness are constructed as definitely different from those

with a mental illness as they are firmly in touch with the accepted social reality.

70

This discourse does not allow for any identification and ‘same-ness’ between

these two groups.

5.5 Mental Illness as Unknown

The most important characteristic of this discourse is that the construct of mental

illness/madness and those diagnosed with it remains unknown to the general

public if they are not directly involved in it. This has many important implications

for how these objects are then constructed by the community.

The participants in the study shared an overwhelming feeling that they had no

knowledge about mental illness, mental patients, or even its treatment:

“No, I don’t know! No, I don’t understand it. It’s hectic because

I don’t understand it.”

“No, no, it is not something that I know…”

“…I must tell you it’s difficult for me to tell you precisely what I

think it is. It is, one has these half confusing images of what

now actually happens.”

As such the community really has no power to speak in this discourse:

“My physical perception thereof is that if you don’t actually

have physical background of what it means or what it entails

or were already physically there yourself or have any

knowledge of what happens there, then it is actually very

difficult to have an opinion.”

71

The participants are left with only their own interpretations to understand mental

illness:

“So I think you take things that are known to you and you

tweak it according to how you think it must be in a hospital.

Because I have no other framework, so I have to take things

that I have already seen and is familiar to be able to link back.”

The major texts used to inform and shape the participants’ constructs of mental

illness are media texts such as books and films, even though these are not

perceived as an accurate description:

“…I think mostly movies. What you have learned in the

movies. Movies and books, I think form a large perception.”

“People watch those movies like “28 Days” where those

people are in rehab with Sandra Bullock and all those other

movies. Except it, it isn’t precisely the true picture, but it is a

bit of an idea of how it can be there.”

Since the community is left to their own devices and the depictions of the media

to construct an understanding of mental illness, the participants suspect that this

creates misunderstandings and misperceptions of what it means to be mentally

ill, and what the treatment for it is:

“…but I think people have a misperception of people that

uh…people like this who are mentally disturbed.”

“…and again you have the perception that the media create

and of you do not know what goes on there, what treatment

the people get, then, then you will most probably be a little

72

scared of it. I think it is important that people know what it

happening there, because if you don’t, then you will, you know

it’s, you are going to create bad perceptions.”

The fact that the larger community has no knowledge of mental illness, those

who experience it and the institutions and professionals who treat it leads to

mental patients being constructed in various ways. Mental patients are perceived

as interesting and exotic, like a mystery or secret that needs to be explored or

discovered:

“…I think you see lots of different characters and the reason I

say it, again each guy is maybe in his own little world and I

know it will be interesting…”

“But I think it will be interesting to see the unknown.”

This view is in contrast with the previous discourses as it constructs mental

patients as almost enticing, and inviting contact from those who have not

experienced a mental illness. It is quite different from the other discourses where

contact is not invited and not desired by the participants. However, some

distance is still maintained by the above participant in that he does not really

crave a relationship, he only wants to “see the unknown”, almost like going to a

circus or zoo. Therefore, even though this discourse constructs those suffering

from mental illness in an interesting light, participants still seem to distance

themselves from any real contact with people with a mental illness and

experience themselves as being different from them. They themselves are not

unknown but predictable and straightforward. In addition, the unknown has a

scary element to it because the general public do not have easy access to

mental patients, and the situation needs to be investigated before they would

take any responsibility towards the mentally ill:

73

“Um I think you need to see and experience it first before you,

before I will just say: “Yes I am going to do my social

responsibility and I’m going to work in the hospital every

weekend.”

Constructing mental illness in this way leaves the participants free to plead

sensitivity and fear as reasons to not have contact with mental patients. This

discursive argument allows the participants to keep an interested but aloof

distance from those with mental illness.

As discussed above, this discourse also constructs those who experience mental

illness/madness as scary and frightening, which makes the general public wary

of interacting with them:

“If I see a hole in the wall I am not going to put my hand

through it. You don’t know what is on the other side.”

“…it’s bad and it is actually shocking…”

The concept of ‘mental illness as unknown’ overlaps with the discourse of ‘mental

illness as bad’ in that mental patients are constructed as potentially violent and

unpredictable:

“I don’t know. I don’t know. It’s a good question. I don’t know. I

will be afraid he snaps.”

The general public may become the victims of these unpredictable and possibly

violent people and this allows people who do not have a mental illness to protect

themselves through distance.

74

People with a mental illness remain voiceless in this discourse as they have no

means to communicate their experiences to the community or any other people

who are not part of the scientific or professional discourse of mental illness. The

community also remains powerless to understand and contribute to this

discourse, even though they seem to find it important to have contact with this

discourse. When people are admitted to an institution they become isolated from

the outside world; and the only voice they have in that discourse is the voice and

interpretations of the media.

“No, I think it is very important that we know what is going on

there or just have a better perception and idea of what is going

on there.”

“…if they understood what those people, the patient go

through if they are there, then maybe people will take off their

hats and one; have respect, one for the people who work there

and for the patients who are there.”

The unknown nature and definition of mental illness renders mental patients

vulnerable to discrimination. Although the participant here uses a discursive

technique to distance himself from this position by referring to the perception of

‘other people’, a discriminatory position or view held of people with a mental

illness is discernible. The distancing allows the participant to voice his opinion

without actually appearing to be prejudiced and discriminatory:

“…I think people think you are going to a cuckoo’s nest or

something and they are um... you know, they’re not normal…”

In this discourse professionals who treat those with a mental illness are

constructed in positions of power as they are the ones who have the knowledge

and understanding of mental illness, its treatment and mental patients. The most

75

powerless in this discourse are ordinary people who have nothing but indirect

means by which to make sense of that reality. As such, the institutions where the

mentally ill are treated and the professionals who treat them benefit from this

discourse; even though the general feeling of the participants is that it should be

dissolved, and more transparency and involvement with the object of the

discourse initiated.

5.6 Mental Illness as Bad

The ‘mental illness as bad’ discourse constructs all its objects and subjects in a

dangerous or harmful way. Those suffering from mental illness are constructed

as dangerous to themselves and others, devious, incurable, mad, insane and

bad for their family. This discourse overlaps with many of the previously

discussed discourses. It constructs mental health professionals as the ones with

the knowledge to cure, although they are also constructed as uncaring and

institutions as punitive, where people are locked up like in a jail to protect others

from them. There are a variety of terms used in this discourse to describe those

suffering from mental illness:

“…that guy was a serial killer or something, he is insane.”

“…then they go off their rockers…”

“…they are actually cuckoos…”

“Shit I will be scared of people like that, because they can just

do something any time…”

“…and then the guy can go commit bloody murder, because

he thinks it is the right thing to do.”

76

“…a guy with maybe any psychopathic tendencies or

something that is very violence…violent or something.”

One of the ways in which these patients are constructed is as having lost their

reasoning ability. If they think murder is the right thing to do then surely they are

not reasoning properly, according to social norms. This resonates with the

Enlightenment construction of madness as the loss of reason (Foucault, 1974).

As can be seen by the cited texts, this discourse is very robust in the way it

shapes mental patients as unpredictable and violent and as a

“…threat to society…”

This becomes particularly worrying in the light that this condition is considered

incurable; it is something that will be present in an underlying form for the rest of

the individual’s life, and can possibly be triggered by life events that might make

the person violent again:

I think underlying it will always, it will always be there.”

“All it does is suppress it and it will build up and build up and

build up.”

The construction of mental patients as potentially dangerous and violent provides

a moral justification for their confinement in psychiatric hospitals. If someone then

has the potential to harm himself and others, then the act of society in confining

them to psychiatric institutions rather than prison is empathic and caring.

However, the ideal (to confine and remove unwanted elements from society)

remains the same:

77

“But you don’t want him in society. It is not the best for him or

for those around him…”

In this discourse mental patients are very powerful in the way that others talk

about them. They have the potential to do powerful damage to others, such as

committing murder and rape. Mental illness is so powerful that it can drive

otherwise caring individuals to wipe out their families:

“…um because one day they can just snap and then you hear

about a dad that killed his whole family and shot himself, or

whatever.”

Those who do not have a mental illness are constructed as the potential victims

of irrational violence and harm to their person. As such, they feel that mental

patients are scary:

“I’ll be a bit afraid;”

and possibly disturbing to have contact with. Even if the mentally ill person is not

violent, the participants fear that contact with them may be damaging:

“I’m too sensitive for these things.”

“…you know it can be very disturbing for me, ten to one, to

see people…”

These constructions of madness/mental illness seem to echo the ideas

discussed by Foucault (1974) in Madness and Civilisation where he discusses

the view of madness in the Classical period. Madness was seen as a

manifestation of animality and therefore violence. The ideal way to deal with this

is through confining the individual to protect humanity from what is bestial.

78

Of all the discourses discussed, this discourse most justifies the distancing of

people without a mental illness from mental patients. The sentiment conveyed is:

“If they are potentially dangerous and we do not know how to handle them or

even understand what they are going through then we cannot possibly be

expected to have contact, can we?” As such, mental institutions are charged with

the protection of society from these possibly harmful individuals. Even the family

becomes exonerated from the care of mentally ill members as it can become too

expensive and too tedious to care for them:

“…then it is a schlep. It becomes tedious I think.”

“…and the medication maybe costs a fortune…”

What is interesting in this discourse is the reluctance of participants to frame

mental patients in a bad light. They do not openly describe mental patients as

bad but use a morally and politically correct manner of speaking when alluding to

mental illness as bad:

“Ok, I’ll be scared of myself, not because I think he’s now

going to take out a knife and stab me… I don’t want them to

see I’m scared of them or they should think I don’t want to talk

to them or something. So I don’t want to make them unhappy.”

“No it’s jail cases. And it is actually bad to say it because

obviously they have psychological problems…”

Through distancing themselves from a negative view of mental patients by using

politically correct ways of speaking, or by saying that these are the views held by

others and not by them, the participants are able to communicate their views of

the mental patient as unpredictable, possibly violent and ‘bad’ without admitting

to their own prejudice:

79

“…and ten to one that is why people in society say: “O jees,

you know that guy was in a mental hospital, we don’t want

anything to do with him…”

In South African society there is currently great sensitivity to prejudice due to our

turbulent history of apartheid, among other things. Although people likely have a

less than favourable picture of people who have a mental illness, they do not

wish to appear judgmental in our highly sensitive society, and may therefore

appeal to morality in supporting their opinions. It seems that although stigma and

prejudice does exist towards mentally ill people, society must guard against

uttering this lest it should appear prejudiced and uncaring.

This discourse overlaps with the ‘mental illness as unknown’ discourse in various

ways. One of the prominent ways is that the general public, having no knowledge

of mental illness, may exacerbate the possibly violent tendencies of mental

patients:

“I’ll be afraid I say the wrong thing and he snaps.”

The same texts used to elaborate and inform both discourses. The general public

(as represented by the participants) have access to the experience of mental

illness and those suffering from it only through the media. Although this is the

only contact they have with the discourse, the media is not always perceived as

giving an accurate depiction of mental illness; moreover, it is perceived as adding

to the construction of mental illness as bad, and to those who have a mental

illness as violent:

“Mostly TV and stuff. Like over the radio, like yesterday, a boy

he is twelve and he was bloody-well stabbed how many times

with a knife.”

80

“You mostly see the negative; you don’t see the positive side

of it actually, or the better side. Otherwise it wouldn’t be on the

news.”

This throws into sharp relief the role that the media has in the construction of

mental illness and the mentally ill. As discussed in the literature survey, the anti-

stigma discourse on the portrayal of mentally ill in the media is that media images

of the mentally ill imply an association or link between mental illness and

violence. This creates the impression that people who are mentally ill are to be

feared. According to the findings of this study, the media is fulfilling just such a

role. However, it seems that this construction provides people without a mental

illness with a good explanation for not initiating contact with the mentally ill, or in

this case, severe ‘badness’. If the general public believes that people with a

mental illness are potentially violent and harmful, then it provides a good moral

argument for the institutionalisation of these individuals and their removal from

society.

This discourse may prove a stumbling block for the reintegration of the mentally

ill into the community, and may open these individuals to possible attack. In this

discourse the construct of mental illness is synonymous with the construct of

violence, and thus it may be difficult for some community members to accept that

these individuals are not confined to an institution. What is also important is that

even thought the participants were reluctant to own these views, and distanced

themselves by stating that these views were held by others, the discourse is very

robust and prominent.

5.7 Discussion

What is important in the discussion of the data is the absence of certain

discourses and voices in the description and experience of mental illness. Absent

from the discourses described above is the spiritual discourse of mental illness.

81

As Foucault (1974) reflected in Madness and Civilisation, the church seems to

have lost its power to define the world. Mental illness is no longer given a divine

explanation and the ‘cure’ therefore can no longer lie in the hands of the church.

No god was called upon to intervene in treatment and no religious doctrine was

enforced to make sense of the experience of mental illness. This reinforces the

power ascribed to mental health professionals and the institutions where they are

trained, as well as the institutions where the mentally ill are treated, as the sole

keepers of knowledge and cure for the mentally ill.

Also absent in all the discourses are cultural explanations of mental illness. As

discussed in the literature survey, many traditional South Africans believe that

mental illness is due to bewitchment from malevolent individuals and the only

cure for this can be sought from a traditional healer or sangoma. The absence of

this discourse may be due to the homogeneity of the participant population,

although it does shed light on the silence of certain voices within the debate on

mental illness. As an intern psychologist working at Weskoppies Hospital it has

become increasingly clear to me that there is very limited space for cultural

descriptions in the experience of mental illness. If a family believes that their

loved one has been bewitched, the multidisciplinary team feels that they need

psycho-education to clear up the family’s misunderstanding of their family

member’s condition, and to assist the family to comply with treatment. It seems

likely that mental health professionals would not encourage a rich description of

mental illness if the use of other discourses put the power and responsibility of

cure into other hands. One of the criticisms often raised against the medical

model of madness as mental illness is that it is culturally one-sided, and shows a

singular lack of responsiveness to different cultures (Louw, 2002). These

critiques are often phrased in terms of a "Eurocentric", "Westocentric" and

"individuocentric" focus (Holdstock, 2000). In a society where many of the

existing cultures are not based on a Western worldview, it is possible that the

construction of madness as mental illness could marginalise and fragment

82

certain elements. However, a greater exploration of the various South African

cultures is needed to fill this gap in the debate on madness/mental illness.

What is also noticeable in these discourses is that the phenomenon of mental

illness is invariably constructed as situated within the individual. This correlates

with the modernist view of the person as a self-contained, rational individual

(Bakker, 1999). In African thought, for instance, rather than dwelling on the

relationship that one has with one's own thoughts and feelings, one ideally

projects oneself "outwards" to establish relationships with the sky, the land and

one's community and kinship group. It seems, therefore, that all the participants

in this study subscribe to the Western discourse of people as self-contained

entities, and discourage the involvement of the community and the family of the

individual. This attitude therefore supports the construction of institutions that are

able to look after these individuals as their family cannot. This view seems to

discourage the reintegration of the mentally ill into the community as the latter will

not be able to understand the phenomenon of mental illness. The consequence

of this is that individuals with a mental illness may be further stigmatised, as

responsibility and fault is situated within the individual.

All five of the discourses exclude the general public and therefore the community

from actual understanding the discourses on mental illness. They do not have the

necessary training and knowledge and so cannot help people with a mental

illness. This is especially prominent in the ‘mental illness as the domain of

professionals and mental institutions’ discourse, as well as the ‘mental illness as

individual experience’ discourse. According to the construction of mental illness

as unknown, the general public cannot obtain access to the discourse, which

creates fear of those with a mental illness because it is unknown territory. How

can the reintegration and care of the mentally ill move to a community level if the

community has no access to the discourse and also no understanding of mental

illness? This is especially worrying in the light of the public’s robust construction

83

of mental patients as unpredictable and possibly violent that is encouraged by

the media.

The most powerful objects and subjects in all the discourses are the mental

health professionals. They are constructed throughout as having the necessary

expertise and knowledge to cure the mentally ill; and in the ‘mental illness as

bad’ discourse are morally sanctioned by the public to confine and treat mental

patients because of their capacity to hurt themselves and others. All the

discourses discussed support the institutions that train professionals

(psychologists and psychiatrists) and that care for the mentally ill. Mental illness

then becomes the sole terrain of mental health professionals who must fathom

and hopefully rectify these irrational maladies (Fee, 2000). They become imbued,

according to Fee (2000, p.3), “with mysterious powers of moral adjudication.”

Even though these professionals are also constructed as uncaring and possibly

not effective, the participants use various techniques to distance themselves from

people with a mental illness and to justify their non-involvement. For example,

they blame the media for creating skewed ideas of the ‘badness’ of the treating

professionals. What is prominent is that none of the discourses place people

without a mental illness in a position that encourages real empathy and real

identification with mental patients. Those on the outside of the discourse seem

for the most part to be comfortable with this distance and even seem to prefer it,

although they state that they would like to understand more of the experience of

madness/mental illness. This may reflect the effect of using the term ‘mental

illness’ described by Corrigan (2007). According to him, using this construction

emphasises the “groupness” of people with a mental illness, but at the same time

accentuates their “differentness” from the general public. It seems that all the

discourses involving the use of the ‘madness as mental illness’ construction

indeed emphasise the “differentness” of those suffering from it and the

participants of the study.

84

The most powerless objects and subjects in the various discourses are the

people who have a mental illness. They do not have the power to speak of their

experiences and they also do not have the relevant scientific knowledge and

therefore need to consult professionals for their cure and management. They do

not have a say in their treatment and confinement, and their opinions on their

suffering are not deemed important. The majority of these discourses construct

mental patients in a less than favourable light. The ‘mental illness as bad’

discourse constructs patients as potentially dangerous; the medical discourse

constructs patients as suffering from an inherent chronic illness that can only be

managed; the ‘mental illness as unknown’ discourse constructs patients as

suffering from something that the general public does not understand and

therefore fears. As a result, members of society are generally reluctant to get

involved in the care of mental patients. In only a few of the discourses are mental

patients constructed in a more positive light. In the discourse of ‘mental illness as

individual experience’ there is a discourse of envy because mental patients do

not have to face the harsh reality of current South African society. In the

psychological discourse, patients are constructed as the victims of difficult life

events, while in the discourse of ‘mental illness as unknown’ mental patients are

constructed as interesting and exotic. This is important when attempting to

reduce societal stigma against the mentally ill. If mental illness is framed as

being the result of difficult life experiences rather than an underlying illness,

community members may be more understanding and willing to become

involved, as it seems that this discourse is the most likely to invite more real

identification and empathy from those who have not experienced such difficult

events.

5.8 Role of the Researcher

This section reflects on my role in gathering and interpreting the data. During the

transcription and the analysis of the texts I have become aware that it was very

difficult for me to stand outside my own use of the term “mental illness” as a

85

means to categorise and describe a certain set of experiences and behaviours. I

invariably introduced the term into my conversations; and in the analysis of the

data I leaned heavily on the term to discuss and describe the different

discourses. It seems that even though I am ambivalent about the usefulness of

this construction in the description of experience, I also subscribe to the medical

discourse to a certain extent. Part of the appeal of this discourse is the efficiency

with which the language used categorises and refers to a broad variety of

experiences and constructs. I can only reflect on the prominence of this

discourse in society today, and state that according to the epistemology that I

have chosen as the basis of this study, no one can be objective and stand

outside of the discourses that shape our societal understandings.

5.9 Conclusion

In this chapter I have discussed the results of the study in terms of five different

discourses identified in the transcripts of the participant interviews that formed

the texts of this study. The five identified discourses are: the scientific discourse

of mental illness; mental illness as the domain of professionals and mental

institutions; mental illness as individual experience; mental illness as unknown;

and mental illness as bad.

The different ways in which people with a mental illness are constructed was

explored and discussed. The majority of those ways seem to construct the

mental patient in an unfavourable light. Some implications for the reintegration of

the mentally ill into their various community settings were also discussed. Finally,

the section concluded with a reflection of the role of the researcher in the

process.

86

������������

�

Conclusion

Every endEvery endEvery endEvery end

Is a newIs a newIs a newIs a new

BegBegBegBeginninginninginninginning

AnonAnonAnonAnon

87

6.1 Introduction

The aim of the study was to explore the constructions of madness/mental illness

among young professionals. The research aimed to gain a deeper understanding

of their experiences and meanings of madness/mental illness through their own

words. This study hopes to form part of a larger ongoing dialogue on mental

illness, and to illustrate the complexity of experience and meaning in this area. It

aimed to amplify the view of mental illness as being the terrain of mental health

practitioners only, by broadening the field to include a diversity of voices on this

topic. The study took the form of a discourse analysis of four transcribed

interviews with young professionals between the ages of 23 to 26.

This research process was described in the previous chapters. Relevant

literature on the construction of madness/mental illness in different historical

periods was discussed, as were the implications of this for both people

diagnosed with a mental illness and those charged with their care and treatment.

The social constructionist underpinning that directed the study was discussed

and the methodology used to analyse the text was described. The discourse

analysis discussed the discourses that emerged from the analysed texts and

these were integrated with the relevant literature.

This chapter represents a final reflection on and evaluation of the research,

discusses the limitations of the study, and makes recommendations for future

research projects.

6.2 Final reflections

In the process of analysing the texts five discourses were identified and

discussed. The first of these discourses was the scientific discourse of mental

illness. In this discourse madness is constructed as an illness with primarily

genetic, chemical or emotional causes. The cure of this illness is seen as the

88

sole responsibility of those who have the proper scientific training and expertise.

The general public seem to have very little knowledge about the meaning of

mental illness, and so defer to the responsibility and knowledge of the experts in

the treatment of the mentally ill.

The second discourse was mental illness as the domain of professionals and

mental institutions. There was a prominent overlap between this discourse and

the scientific discourse, in that mental health practitioners are seen as the

relevant authorities to deal with those who do not act according to the social

norm. For the most part the participants seem comfortable with this idea and use

distancing strategies to explain their non-involvement in the care of the mentally

ill. What is interesting about this discourse is that both the experts and the

patients are constructed as ‘bad,’ with patients who are child-like and in need of

care, and professionals who are uncaring and sometimes even ruthless in their

treatment of the patients. Discursively, participants plead ignorance of the

discourse and blame the media for creating skewed ideas of the treating

professionals in order to abdicate responsibility for acting on these perceptions of

mental health professionals.

Mental illness as individual experience was discussed as the next discourse. In

this discourse the experience of mental illness is seen as an exclusive

experience to which very few except the diagnosed individuals themselves have

access. It places the participants in an outsider position where they are

powerless to understand and even reach those who have this condition. There

was some envy towards those who are able to create their own isolated world

and who ostensibly have the ability to escape the harsh reality of current society;

although it is acknowledged that this results in their being the victims of ridicule

from those who cannot access their world.

The fourth discourse is the mental illness as unknown discourse. In this

discourse mental illness/madness, the mentally ill, and the treatment of mental

89

illness are a mystery to those who are not part of these experiences. The only

players who have access to this discourse are mental health practitioners as

scientifically trained experts, and the mentally ill themselves.

The final discourse is mental illness as bad. In this discourse those with a mental

illness are constructed as dangerous, possibly violent, unpredictable and

damaging. This discourse positions those who do not have a mental illness as

the possible victims of these individuals and in need of protection. It justifies the

institutionalisation of mental patients and imbues these institutions with absolute

power and moral responsibility. Unwanted elements need to be removed from

society.

One of the aims of the study was to amplify the view of madness/mental illness

as being the domain of mental health practitioners alone. The results suggest

that those on the outside of the mental health discourse seem to prefer the fact

that only specially trained individuals are responsible for the cure and treatment

of the mentally ill; and may use many techniques to stay uninvolved.

The study also emphasises how pervasive the construction of madness as a

mental illness is among the participants; and how spiritual and cultural

explanations in these discourses are marginalised.

6.3 Evaluating Discourse Analysis

In this section some possible ways for evaluating this discourse analysis are

discussed. This is necessary to discuss the status of knowledge within discourse

analysis. The epistemological claims in discourse analysis differ from that of

traditional, modernist research (Wetherell et al., 2001). Traditional research aims

to produce knowledge which is value-free, objective and generalisable (Taylor,

2001a). The aim is to gain knowledge of the world as it is and of the workings

90

thereof, and in particular, to gain insight into the causal relationships between

events and objects (Taylor, 2001a).

However, discourse analysis does not aim to discover these objective truths but

rather sees knowledge as interpretations or versions of reality (Taylor, 2001a).

This is in keeping with the social constructionist approach of the study. The study

did not aim to produce generalisable truths about what it means to be mentally

ill/mad, but aimed to represent a situated set of meanings. The meanings

discussed in this study were derived from a very particular group of people, and

as such they do not form a representative segment of the entire South African

population; and their views are certainly not held by all South Africans. However,

they can be considered to form a “representative horizon of meaning” (Holstein &

Gubrium, 1995, p. 74), as discussed in the methodology section, and as such

their specific situated meaning is important as representative of a segment of the

population.

Taylor (2001b) suggests some further useful methods for evaluating discourse

analysis. Discourse analysis can be evaluated through looking at the quality of

the interpretation, the relevance and the usefulness of the research (Taylor,

2001b). The relevance of this research lies in the way that relationships are

constructed within the differing discourses and the relative power imbalances

within it. By identifying and deconstructing certain discourses, new realities can

be created and power imbalances can be addressed. The meanings emerging

from this discourse analysis give some reference to the perceptions of madness

and mental illness that are held by some South Africans. It is evident that the

participants in the study have very little knowledge and contact with people who

have a mental illness, and also employ a great number of strategies in order to

maintain their distance from these people. As such, they rely heavily on specially

trained professionals to manage and cure those with a mental illness/madness

and the institutions that confine them during their period of illness/madness.

Importantly, the constructions of mental patients as dangerous, unpredictable

91

and scary seem to be fuelled by the fact that the participants have no knowledge

of mental illness and find it unsettling, and the fact that the media portrays a

mostly negative image of people with a mental illness. If the South African Health

Department wishes to reintegrate and care for patients at community level, this

study proposes that more transparency is needed regarding the treatment and

understanding of mental illness for those who do not have a mental illness and

have no contact with discourses on these experiences.

One way to determine the rigour of a discourse analysis is by examining the

richness of the detail of the analysis. Inconsistencies within discourses should

have been highlighted and investigated (Taylor, 2001b). To obtain a rigorous

analysis I discussed findings with my supervisor and colleagues in order to

broaden the possible interpretations and analysis of the interviews. The analysis

is also placed in relation to previously published works on the research subject

highlighted in the literature survey, in order to obtain a more rigorous analysis

(Taylor, 2001b).

Another important consideration is the role of the researcher. Within this

approach the researcher cannot be separated from the research, and the identity

of the researcher will have an impact on the research (Taylor, 2001a). The aim

therefore is not for researchers to be as neutral as possible, but to reflect on their

part in the research process. This was done throughout the research project.

6.4 Limitations of the Study

As was discussed above, the participants of this study form only a representation

of a segment of the South African population. All of the participants were

Afrikaans speaking, white individuals from a very similar cultural and

socioeconomic background. As such, there are still many silent voices from the

community. The meanings of black, Indian and coloured South African were not

explored, and neither were the meanings of the very poor. Consequently, this

92

study only represents a starting point in the discussion of the views of

madness/mental illness of the South African population.

The study was also based on a very small participant sample. Even though the

information in this study gives a rich explanation for the situated meanings of

these individuals, more information is needed before this information can be used

to inform policy making or treatment programmes.

6.5 Recommendations

Based on the findings of the study and its limitations, the following

recommendations are made. In order to explore the views of a broader segment

of the South African population further studies could examine the meaning of

different cultural, socioeconomic and demographic groups in South Africa. As the

views of the general public influence how those with a mental illness are treated,

and in the light of moves to reintegrate mentally ill people into their community, it

is important to explore these meanings in the broader community.

This study also illustrates how little knowledge the participants have of the

experience of mental illness/madness. Consequently, they seem to fear contact

with the mentally ill. It would be valuable to explore the possibilities of greater

transparency in the treatment and understanding of mental illness to reduce this

fear in the community.

An exploration of the media’s influence in shaping people’s ideas of mental

illness/madness also seems warranted. As this study illustrates, the participants

seem to experience the media images they are exposed to as mostly negative,

and find that they paint people with a mental illness in an unfavourable light.

93

6.6 Final Reflections

During this study many of my personal ideas on the experience and perception of

mental illness were influenced. I hypothesised that the distance between the

general public and those with madness/mental illness was imposed only by

mental health professionals in an attempt to protect the rights of their charges.

During this study I became aware that people who do not have a mental illness

also desire this distance, as they construct mental patients as being dangerous

and possibly violent. It was difficult for me to distance myself from this

emotionally, as one of my most important interests is the possibility of lessening

stigma towards people with a mental illness. Although this was not the focus of

the study, this finding has sparked my own interest in possible ways of lessening

stigma and prejudice towards people with a mental illness. One of the areas

which I would like to investigate further is increasing the contact between the

general public and people with a mental illness. Would this have the effect of

lessening fear and a need to distance oneself from ‘mad’ people, or would it

reinforce this tendency?

94

REFERENCES

Babbie, E., & Mouton, J. (2002). The practice of social research. Pretoria:

Oxford University Press.

Bakker, T.M. (1999). A healer may yet emerge from behind the modernist mask:

Revisiting the tarnished image of psychology in Africa. A South African

perspective. Journal of Psychology in Africa, 9(2), 161-185.

Barlow, D.H., & Durand, V.M. (2002). Abnormal psychology. An integrative

approach. Belmont, CA: Wadsworth.

Becvar, D.S., & Becvar, R. J. (1996). Family therapy: A systemic integration (3rd

ed.). Boston: Allyn & Bacon.

Becvar, D.S., & Becvar, R.J. (2000). Family therapy: A systemic integration (4th

ed.). Boston: Allyn & Bacon.

Beuster, J.T.R. (1997). Psychopathology from a traditional southern African

perspective. Vista Occasional Papers, 5(1), 89-98.

Blazer, D. (2007). Spirituality, depression and suicide: A cross-cultural

perspective. Southern Medical Journal, 100(7), 735-736.

Burman, E. & Parker, I. (Eds). (1993). Discourse analytic research: repertoires

and readings of texts in action. New York: Routledge.

Burr, V. (1995). An introduction to social constructionism. London: Routledge.

95

Casey, B., & Long, A. (2003). Meaning of madness: A literature review. Journal

of Psychiatric and Mental Health Nursing, 10, 89-99.

Castillo, R.J. (Ed). (1998). Meanings of madness. Thousand Oaks, CA:

Brooks/Cole.

Connor-Greene, P.A. (2006). Interdisciplinary critical inquiry: Teaching about

the social construction of madness. Teaching Psychology, 33(1), 6-13.

Corrigan, P.W. (2007). How clinical diagnosis might exacerbate the stigma of

mental illness. Social Work, 52(1), 31-39.

Corrigan, P.W., Green, A., Lundin, R., Kubiak, M., & Penn, D.L. (2001).

Familiarity with and social distance from people who have serious mental illness.

Psychiatric Services, 52(7), 953-958.

Corrigan, P., & Watson, A. (2002). The paradox of self-stigma and mental

illness. Clinical Psychology: Science and Practice, 9(1), 35-53.

Doan, R.E. (1997). Narrative therapy, postmodernism, social constructionism,

and constructivism: Discussion and distinctions. Transactional Analysis Journal,

27(2), 128 – 133.

Durrheim, K. (1999). Research design. In M. Terreblanche & K. Durrheim

(Eds.), Research in practice (pp.29-53). Cape Town: University of Cape Town

Press.

Edwards, D.J.A. (1998). Types of case study work: A conceptual framework for

case based research. The Journal of Humanistic Psychology, 38(3), 36-70.

96

Fairclough, N. (2003). Analysing discourse: Textual analysis for social

research. London: Routledge.

Fee, D. (Ed). (2000). Pathology and the postmodern. London: Sage.

Felman, S. (1985). Writing and madness. New York: Cornell University Press.

Freedman, J., & Combs, G. (1996). Narrative therapy. The social construction

of preferred realities. New York: Norton.

Foucault, M. (1972). The archeology of knowledge. London: Routledge.

Foucault, M. (1974). Madness and civilization: A history of insanity in the age of

reason. London: Routledge.

Foucault, M. (1995). Madness, the absence of work. Critical Inquiry, 21, 290-

298.

Gergen, K.J. (1999). An invitation to social constructionism. London: Sage.

Gergen, K. (2001). Social construction in context. London: Sage.

Gingerich, S.L. (1998). Stigma: Critical Issues for clinicians assisting individuals

with severe mental illness – response paper. Cognitive and Behavioral Practice,

5(2). 277-284.

Gough, H. (1971). Some reflections of the meaning of psychodiagnosis.

American Psychologist, 26, 160-167.

Hanson, B.G. (1995). General systems theory beginning with wholes.

Washington, D.C.: Taylor & Francis.

97

Harper, S. (2005). Media, madness and misrepresentation: Critical reflections

on anti-stigma discourse. European Journal of Communication, 20(4), 460-483.

Henning, D. (2005). Courage under fire: Stories of adolescents who survived

the destruction of divorce. Unpublished Masters dissertation: University of South

Africa, Pretoria.

Holdstock, T.L. (2000). Re-examining psychology. Critical perspectives and

African insights. London: Routledge.

Holmes, P.E., & River, L.P. (1998). Individual strategies for coping with the

stigma of severe mental illness. Cognitive and Behavioral Practice, 5(2), 231-

239.

Holstein, J.A., & Gubrium, J.F. (1995). The active interview. Thousand Oaks,

CA: Sage.

Hughes, L. (2002). Paving pathways. Child and adolescent development.

Wadsworth: Belmont.

Kvale, S. (1996). Interviews: An introduction to qualitative interviewing.

Thousand Oaks: Sage.

Kvale, S. (1992a). Introduction: From the archaeology of the psyche to the

architecture of cultural landscapes. In S. Kvale (Ed.), Psychology and

postmodernism (p. 1-16). London: Sage.

Kvale, S. (1992b). Postmodern psychology: A contradiction in terms? In S.

Kvale (Ed.), Psychology and postmodernism (p. 31-57). London: Sage.

98

Laing, R.D. (1965). The divided self: An existential study in sanity and madness.

London: Tavistock.

Littlewood, R. (2001). Psychotherapy in cultural contexts. Psychiatric Clinics of

North-America, 24(3), 507-522.

Louw, J. (2002). Psychology, history, and society. South African Journal of

Psychology, 32(1), 1-8.

Lyotard, J. (1984). The postmodern condition: A report on knowledge.

Minneapolis: University of Minnesota Press.

Madlala-Routledge, N. (2004). Budget speech by Deputy Minister of Health,

Nozizwe Madlala-Routledge. Retrieved May 15, 2007, from:

http://pmg.org.za/briefings/040617dephealth.htm

Mahrer, A.R. (1988). Discovery-oriented psychotherapy research: Rational and

aims. American Psychologist, 43, 694-702.

McHoul, A., & Grace, W. (1998). A Foucault primer: Discourse, power and the

subject. Melbourne: Melbourne University Press.

Meese, D.G. (2005). Seeing the wood for the trees: The experience of

genograms and family sculpting during clinical psychology masters training.

Unpublished Masters dissertation: University of Pretoria, South Africa.

Miller, J. (1983). The myth of mental illness: A conversation with Thomas

Szasz. The Sciences, 22-30.

Mills, S. (2003). Michel Foucault. London: Routledge.

99

Mirowski, J., & Ross, C.E. (1989). Psychiatric diagnosis as reified measure.

Journal of Health and Social Behavior, 30(1), 11-25.

Morgan, A. (2000). What is narrative therapy? An easy to read introduction.

Adelaide: Dulwich Centre Publications.

Nevid, J.S., Rathus, S.A. & Greene, B. (2000). Abnormal psychology in a

changing world.(4th ed.) Upper Saddle River: Prentice Hall.

Painter, D., & Theron, W.H. (2001). Heading south! Importing discourse

analysis. South African Journal of Psychology, 31(1), 1-8.

Palmer, D. (2000). Identifying delusional discourse: Issues of rationality and

power. Sociology of Health & Illness, 22(5), 661-678.

Parker, I. (1992). Discourse dynamics: Critical analysis for social and individual

psychology. London: Sage.

Rapmund, V.J. (1996). Social support and depression in women: A

constructivist approach. Unpublished master’s dissertation: University of South

Africa, Pretoria.

Rosen, G. (1968) . Madness in society. London: Routledge & Kegan Paul.

Sey, J. (1999). Postmodernism: a critical practice? In M. Terre Blanche and K.

Durrheim (Eds), Research in practice: applied methods for the social sciences.

(p. 462-475). Cape Town: UCT Press.

Struwing, F.W. & Stead, G.B. (2001). Planning, designing and reporting

research. Cape Town: Pearson Education South Africa.

100

Snyman, S. & Fasser, R. (2004). Thoughts on ethics, psychotherapy and

postmodernism. South African Journal of Psychology. 34(1), 72-83.

Taylor, S. (2001a). Locating and conducting discourse analytic research. In M.

Wetherell, S. Taylor & S.J. Yates (Eds.), Discourse as data: A guide for analysis

(pp. 5-48). Walton Hall: The Open University.

Taubes, T. (1998). “Healthy avenues of the mind”: Psychological theory building

and the influence of religion during the era of moral treatment. American Journal

of Psychiatry, 155(8), 1001-1007.

Taylor, S. (2001b). Evaluating and applying discourse analytic research. In M.

Wetherell, S. Taylor & S.J. Yates (Eds.), Discourse as data: A guide for analysis

(pp. 311-330). Walton Hall: The Open University.

Tone, A. (2005). Listening to the past: History, psychiatry, and anxiety.

Canadian Journal of Psychiatry, 50(7), 373-380.

Wassenaar, D.R. (1998). A history of ethical codes in South African psychology:

An insider's view. South African Journal of Psychology. 28(3), 135-145.

Wetherell, M., & Potter, J. (1988). Discourse analysis and interpretative

repertoires. In C. Anataki (Ed.), Analysing everyday explanation: A case book of

methods (pp. 168-183). London: Sage.

Wetherell, M., Taylor, S., & Yates, S.J. (2001). Discourse as data: A guide for

analysis (pp. 311-330). Walton Hall: The Open University.

Willig, C. (2001). Introducing qualitative research in psychology. Buckingham:

Open University Press.